INDONESIA EMERGENCY RESPONSE TO COVID-19 ADDITIONAL FINANCING (P175759) PROGRAM FOR RESULTS ADDENDUM TO THE ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT – DRAFT REPORT (ESSA) May 2021 Prepared by the World Bank Disclaimer: This document is a draft and the information contained herein is subject to change as this document is currently being finalized. ABBREVIATIONS AND GLOSSARY TERM EXPANDED TERM/ DEFINITION AIIB Asian Infrastructure Investment Bank AF Additional Financing BBTKLPP Environmental Health and Disease Control Centre or Balai Besar Teknik Kesehatan Lingkungan Dan Pengendalian Penyakit BNPB National Disaster Management Authority or Badan Nasional Penanggulangan Bencana BPJS National Social Health Insurance Agency or Badan Penyelenggaran Jaminan Sosial BPKP Finance and Development Monitoring Agency BPOM National Agency for Drugs and Food or Badan Pengawas Obat dan Makanan BSSN State Cyber and Code Agency or Badan Siber dan Sandi Negara CCE Cold Chain Equipment CDC U.S. Centre for Disease Control CHAI Clinton Health Access Initiative CISDI Center for Indonesia’s Strategic Development Initiatives (CISDI) COVAX COVID-19 Vaccines Global Access Facility COVID-19 Coronavirus Disease 2019 DFAT Australia’s Department of Foreign Affairs and Trade DG Director General DLI Disbursement Linked Indicator DTKS Database for Social Protection or Data Terpadu Kesejahteraan Sosial E&S Environment and Social ESFT Essential Supplies Forecasting Tool ESSA Environmental and Social Systems Assessment EUA Emergency use Authorization Fasyankes Fasilitas Pelayanan Kesehatan FGRM Feedback and Grievance Redress Mechanism GAVI Global Alliance for Vaccine and Immunization GDPR General Data Protection and Regulation GIIP Good International Industry Practice GOI Government of Indonesia GPS Global Positioning System GRS Grievance Redress System HCF Health Care Facilities HRH Health Care Resources IBRD The International Bank for Reconstruction and Development IPC Infection Prevention and Control I-SPHERE Indonesia – Supporting Primary Health Care Reform ITAGI Indonesia Technical Advisory Group on Immunization JKN National Health Insurance Program or Jaminan Kesehatan Nasional KARS Hospital Accreditation Commission or Komisi Akreditasi Rumah Sakit KIPI Immunization side effects or Kejadian Ikutan Paska Imunisasi KKI Indonesian Medical Council or Komite Kesehatan Indonesia KPCPEN Committee for Handling COVID-19 and National Economic Recovery or Komite Penanganan COVID-19 dan Pemulihan Ekonomi Nasional KNKP National Commission for Patient Safety or Komite Nasional untuk Keselamatan Pasien KTKI Council of Health Human Resource or Komisi Tenaga Kesehatan Indonesia KTP Civil ID Card Kartu Tanda Penduduk LGBTQi Lesbian, Gay, Bisexual, Transgender, Queer and Intersexed MENKES Ministry of Health or Kementerian Kesehatan (same as MOH) MKDKI Indonesian Medical Disciplinary Board or Majelis Kehormatan Disiplin Kedokteran Indonesia MOEF Ministry of Environment and Forestry MOF Ministry of Finance MOH Ministry of Health MOHA Ministry of Home Affairs MTR Mid-Term Review mRNA Messenger Ribonucleic acid MUI Indonesia Ulema Council or Majelis Ulama Indonesia NCD Non-communicable Disease NGO Non-Governmental Organisation NIHRD National Institute for Health Research and Development NIK Civil Registration Number or Nomor Induk Kependudukan OHS Occupational Health and Safety P-Care Primary Care Application PAP Program Action Plan PCR Polymerase Chain Reaction PDO Program Development Objective Permen Ministerial Regulation Perpres Presidential Regulation PPSDM Planning and Empowerment of Human Resource for Health or Badan Pengembangan dan Pemberdayaan Sumber Daya Manusia Kesehatan PforR Program-for-Results Polindes Village level delivery posts or Pondok bersalin desa Posyandu Village health posts PP Government Regulation or PP PPE Personal Protective Equipment Pusdatin Center for Health Data and Information or Pusat data dan informasi Puskesmas Public Primary Health Center Pustu Auxiliary puskesmas RA Result Area Renstra Health Strategic Plan or Rencana Strategis Rorenggar Bureau of Planning and Budgeting SAGE Strategic Advisory Group of Experts on Immunization SIAK Population Administration Information System or Sistem Informasi Administrasi Kependudukan SISDMK Information System on Health Human Resources or Sistem Informasi Sumber Daya Manusia Kesehatan SMILE Immunization and Logistic Electronic Monitoring System or Sistem Monitoring Imunisasi dan Logistik Secara Elektronik SMS Short Message Service SNARS National Hospital Accreditation Standard or Standard National Akreditasi Rumah Sakit SOE State-Owned Enterprise SOP Standard Operating Procedure SRA Stringent Regulatory Authorities SUSENAS The National Socioeconomic Survey or Survey Sosial Ekonomi Nasional UNICEF United Nations Children’s Fund USAID The United States Agency for International Development VRAF Vaccine Readiness Assessment Framework VRAT Vaccine Introduction Readiness Assessment Tool WB World Bank WBG World Bank Group WHO World Health Organization TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................................................ iv A BACKGROUND AND SCOPE ........................................................................................................................... 9 A.1 PROGRAM DESCRIPTION.................................................................................................................................. 9 A.2 PROGRAM BOUNDARIES AND ACTIVITIES ....................................................................................................... 9 A.3 SCOPE OF THE ESSA ADDENDUM ................................................................................................................. 11 A.4 APPROACH TO THE ESSA .............................................................................................................................. 12 B STAKEHOLDER ENGAGEMENT ................................................................................................................. 14 C POLICY, REGULATORY AND INSTITUTIONAL FRAMEWORK ......................................................... 16 C.1 POLICY, LEGAL AND REGULATORY FRAMEWORK ......................................................................................... 16 C.1.1 COVID-19 Vaccination Program ......................................................................................................... 16 C.1.2 Prioritization and Allocation ............................................................................................................... 17 C.1.3 Targetting ............................................................................................................................................. 18 C.1.4 Hazardous Waste Management ............................................................................................................ 19 C.1.5 Occupational Health and Safety ........................................................................................................... 20 C.1.6 Public Health and Safety, including Patient Consent........................................................................... 21 C.1.7 Feedback and Grievance Mechanism................................................................................................... 23 C.1.8 Data and privacy .................................................................................................................................. 24 C.2 INSTITUTIONAL RESPONSIBILITIES ................................................................................................................ 24 D INSTITUTIONAL CAPACITY AND PERFORMANCE ASSESSMENT ................................................... 31 D.1 IMPLEMENTATION OF ENVIRONMENTAL AND SOCIAL ACTION PLANS OF THE PARENT PFORR ..................... 31 D.2 COVID-19 VACCINATION PROGRAM ........................................................................................................... 32 D.3 ENVIRONMENTAL AND SOCIAL CONSIDERATIONS ........................................................................................ 34 D.3.1 Allocation and Prioritization ................................................................................................................ 34 D.3.2 Population Targeting and Exclusion .................................................................................................... 35 D.3.3 Equity and Accessibility ....................................................................................................................... 38 D.3.4 Public Health Communication ............................................................................................................. 39 D.2.4 Hazardous waste management ............................................................................................................. 40 D.3.5 Occupational Health and Safety (OHS) ............................................................................................... 42 D.3.6 Public Health and Safety related to Vaccine Quality and End-to-End Supply Chains and Logistics Management Systems ............................................................................................................................ 43 D.3.7 Feedback and Grievance Mechanism................................................................................................... 44 D.3.8 Data and Privacy.................................................................................................................................. 45 E ENVIRONMENTAL AND SOCIAL RECOMMENDATIONS AND ACTIONS ....................................... 47 F ENVIRONMENTAL AND SOCIAL RISK RATING .................................................................................... 57 G BIBLIOGRAPHY .............................................................................................................................................. 60 LIST OF ANNEXES ANNEX 1: Summary of DLIs for the Additional Financing .................................................................................63 ANNEX 2: Intermediate and PDO indicators, by Results Area (new AF indicators in blue) ................................69 ANNEX 3: Implementation Progress of Environmental and Social Action Plans of the Parent’s PforR ..............71 ANNEX 4: Core Principles and Planning Elements of PforR ...............................................................................79 ANNEX 5: Preliminary Environmental and Social Screening ..............................................................................88 ANNEX 6: Minutes of Stakeholder Consultations................................................................................................94 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 3 LIST OF TABLES Table 1: Stakeholders Consulted in the Preparation of the Program. ....................................................................14 Table 2: GoI Planned Allocation of COVID-19 Vaccination ................................................................................18 Table 3: Institutional Responsibilities for Environmental and Social Performance ..............................................26 Table 4: GoI’s Vaccine Procurement Plan (source: MOH) ....................................................................................32 Table 5: Vaccine Prioritization ..............................................................................................................................34 Table 6: Environmental and Social Action Plans ...................................................................................................48 LIST OF FIGURES Figure 1. Distribution of medical waste processing facilities and transporters ......................................................41 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 4 EXECUTIVE SUMMARY 1. An Additional Financing (AF) to the on-going Indonesia Emergency Response to COVID-19 Program (P173843) is being prepared to support the Government of Indonesia (GoI) in its efforts to enable affordable and equitable access to vaccines across the country. The Program Development Objective (PDO) of the AF remain unchanged – “to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Indonesia�. The Ministry of Health (MOH) remains the implementing agency of the program, with slight adjustment to include Ministry of Health’s immunization sub-directorate. The overall coordination responsibility remains with the Secretary General’s Bureau of Planning and Budgeting. 2. The program boundary has increased at MTR, fueled by the rising number of COVID-19 cases and rising budget needs for detection and treatment. In addition, the program boundary has been further augmented during this AF to accommodate: a. Continuation of the existing response in 2021 through additional budget already allocated for the MOH. This includes for COVID-19 patients treatment, incentives and compensation to human resources in the health sector, and testing supplies, PPE and critical care related equipment. b. Health system preparedness for COVID-19 vaccination for COVID-19 vaccination such as developing policy frameworks for the safe and effective deployment of COVID vaccines. c. Safe and effective deployment of COVID-19 vaccines by supporting strengthened planning processes to establish guidelines and institutional frameworks and thereafter support the GOI programs to bring immunization systems and service delivery capacity to the level required to successfully deliver COVID-19 vaccines at scale. 3. The PforR is not envisioned to support infrastructure investments and/or infrastructure-financing instruments for the construction and rehabilitation of healthcare facilities or cold-chain infrastructure. The PforR Program does not require infrastructure investments for the achievement of the PDO and/or Disbursement Linked Indicators (DLIs). 4. The scope of the ESSA addendum covers a) implementation progress of the environmental and social plans as recommended through the original ESSA, b) assessment of system capacities within implementing agencies for additional activities included in the AF. Environmental and social aspects, defined as areas of concerns, reviewed as part of this ESSA addendum cover a) population targeting, social inclusion and equity; b) public health communication and stakeholder engagement; c) individual rights to vaccination and consent, particularly amongst population groups who are sceptical and/or refuse vaccination; d) handling of grievances, including pharmacovigilance measures to monitor adverse events; e) individual data privacy; e) environmental pollution and community health and safety issue related to the handling, transportation and disposal of COVID-19 vaccine wastes (i.e. syringes, vials, PPEs, etc.); f) vaccine safety related to end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management – including rigorous cold chain control; g) Occupational Health and Safety (OHS). These areas of concern are aligned with the World Bank’s Vaccine Readiness Assessment Framework (VRAF). 5. Similar to its parent PforR, the environmental and social risk is deemed to be substantial. There is a likelihood the Program would lead to some E&S consequences, but the risks are predictable and can be managed through risk management measures. The current strain capacity of MOH in responding to the pandemic may contribute to the possibility of the program may not achieve its E&S operational objectives or sustain the desired E&S results. 6. GoI’s COVID-19 vaccine program aims to provide free vaccines to its entire adult population, or 181.5 million people, recognizing such vaccination as key to reducing morbidity and mortality, as well as for economic recovery from the pandemic. This makes Indonesia a frontrunner among middle income Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 5 countries of its size, in committing to free access to COVID-19 vaccines for everyone. GOI’s prioritization criteria are generally aligned with the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and Indonesian Technical Advisory Group on Immunization (ITAGI). COVID- 19 vaccination seeks to focus on reduction of direct morbidity and mortality and maintenance of most critical services, while considering reciprocity towards groups that have been placed at disproportionate risks to mitigate consequences of this pandemic (i.e. frontline health workers). There are about 181.5 million people to be vaccinated (or 67 percent of the population), requiring 426 million doses of vaccines with a double-dose regimen and assuming 15 percent wastage. The GOI’s adoption of the SAGE/ITAGI recommendation to include the elderly (above 59 years old) in the national vaccination program has been supported with the confirmation of vaccine efficacy and safety from the Indonesian regulatory authority, BPOM (National Food and Drug Control Agency) and vaccination for those over 60 years of age has commenced in February 2021. 7. While it is acknowledged that under the pandemic situation the GoI will need to thread and balance carefully the human wellbeing objective (of reducing COVID 19-related deaths and morbidity) and the objective of economic recovery especially in making decisions about prioritized groups, there are concerns that the government may focus on economic recovery more than public health goal. There may be trade-off but there are also ways to reconcile the two objectives. Prioritizing healthcare workers, essential sectors, elderly and vulnerable populations may help to reduce the number of deaths and severe illnesses, to ease the strain on the health system, and at the same time contribute to economic recovery. 8. The Presidential Regulation no. 14/2021 on COVID-19 vaccination introduces administrative sanctions for refusal of vaccination. However, whether and how sanctions will be enforceable is unclear and is a matter of debate since there are no guidelines and/or operational manuals to enact relevant provisions on sanctions in the regulation. Under this PforR, public health communication for COVID-19 vaccination should emphasize persuasion. A legal covenant has been agreed to ensure that the GOI carries out the Program in conformity with, inter alia, best practices in public vaccination. Provisions for medical exemptions are also already included in the technical guidelines of the MOH, which also forms part of the screening by health workers prior to each vaccination. 9. Disparity between hazardous medical waste volume and the processing capacity remains the biggest challenge in managing COVID-19 related wastes in Indonesia, especially in the regions outside Java. More than half of licensed medical waste processing facilities and transporters are located in the island. It is expected that additional medical waste generated from COVID-19 vaccination activities may add more burden to the now-strained medical waste management system. MOH and MOEF have conducted various efforts in improving medical waste management in the country, these include distributing and constructing additional medical waste processing equipment, developing and disseminating COVID-19 waste management guidelines, and conducting training and webinar for healthcare workers and local environment/health agencies. Additional guidance on management of waste during vaccination activities is already included in the recently published vaccination technical guideline. Continuous interagency cooperation in addressing concerns related to medical waste management and its supervision remains critical in ensuring the proper implementation of relevant regulations and guidelines. 10. There is a risk of COVID-19 exposure to healthcare workers during vaccination activities. Specific measures pertaining to OHS requirements during vaccine administration are included in the MOH’s technical guideline for COVID-19 vaccination. The measures include a) priority vaccination for those administering vaccination, including supporting personnel; b) application of health and basic hygiene protocols, and use of PPEs, c) social distancing requirements, d) fatigue management by capping daily quotas. Additional PPE supplies for healthcare workers and other personnel involved in the vaccination program is also needed. Logistical planning for vaccination, which consider the needs to assess and procure PPEs, is also prescribed in MOH’s technical guideline. A system to monitor the distribution of vaccines and other logistics, including PPEs, have been developed. The implementation of this monitoring system is critical to ensuring healthcare workers are properly equipped with PPE so as to minimize exposure risk. Prioritizing healthcare workers to receive the vaccines is expected to provide Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 6 infection protection to these workers as frontliners. Over 93% of all health workers are now fully vaccinated (a large proportion of the remaining health workers are believed to have been exempted due to medical reasons). 11. People in remote areas, including vulnerable groups such as Indigenous Peoples and marginalized groups such as people with disabilities, Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTQI) persons, religious minorities may face constraints in accessing COVID-19 vaccines despite their willingness to be vaccinated. The assessment acknowledges that access equity remains low, with disparities in geographical access, health worker distribution, and quality of services, particularly in Eastern Indonesia. People who are not part of any government’s registries or whose domicile do not match their administrative records may be excluded. This population may include, but not limited to, circular or seasonal migrants, homeless people and street children, transgender population, and isolated populations. There are risks for individuals without Single Identity Numbers (Nomor Induk Kependudukan or hereafter NIK) may potentially be excluded with a new requirement for NIK as an eligibility criterion which has been required by the anti-corruption commission for accountability of vaccine usage. As the transmission is disproportionately high in urban areas, certain urban populations might also be inadvertently excluded from targeting and identification due to mismatch between their actual residential address and their administrative records. They include people living in informal settlements, newly arrived migrants who have not updated their administrative record, as well as seasonal and transient migrants (including migrant students). Measures to address exclusion errors through bottom-up processes are therefore critical understanding that there are likely loop holes in the existing One Data Information System for COVID-19 Vaccination. Such measures will need to be inclusive, responsive and agile to inform vaccination planning due to limited availability of vaccines in the near and medium-term. 12. Gender inequalities may likely exacerbate access to vaccination. These may stem from access issues (i.e. access to information, services, and trade-offs with domestic responsibilities) as well as socio- cultural barriers where men may get prioritization. Further, since pregnant women are not eligible for vaccination, it is not clear with regards to their access following labor and/or whether there will be prioritization for women who expect pregnancy prior to vaccination. Women-friendly and safe spaces for vaccine delivery are also an important element to ensure well-being of women during vaccination. Understanding that COVID-19 vaccination may take up precious health resources, which are already strained particularly in lagging regions, there are risks that such a program may disrupt the regular maternal health services, including ante- and post-natal care. Under the PforR, measures to promote accessibility and availability of non-COVID-19 essential health services have been agreed with MOH. 13. A guideline for personal data protection for the purpose of COVID-19 vaccination has been developed by the MOH’s Center of Data and Information. The guideline needs to be further operationalized to include relevant measures in the event of breach, violation to the integrity pacts, and data leakages. Under this PforR, the extent of personal data being shared and collected throughout the vaccination process should adhere to the minimum standard and purposive limitation of individual data privacy in line with the General Data Protection and Regulation (GDPR), which is the main reference for the Personal Data Protection Bill. No information irrelevant to the vaccination program could be shared and/or collected. The development and use of the population database registry should only be used for vaccination purposes and individual privacy should be protected. Individual identifying data should only be accessible to officials and workers associated with the implementation of vaccination and should not be shared with other parties without consent from authorities. 14. The proposed environmental and social action plans under the AF correspond to relevant risks considered within the scope of the ESSA (refer Section E). The focus will be on enhancing the capacity of the MOH as the implementing agency to provide technical guidance, oversight, and capacity building for environmental and social risks, particularly on aspects related to population targeting, social inclusion and equity; public health communication strategy and stakeholder engagement; individual rights to vaccination and consent; handling of grievances; individual data privacy particularly with regards to individual targeting and tracing; handling of hazardous medical wastes from vaccination Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 7 activities; OHS and working conditions associated with the transportation, distribution and administration of vaccines and; community health and safety associated with vaccine quality and end- to-end supply chain and logistics management systems. 15. Due to COVID-19 travel restrictions, virtual consultations for the AF preparation have been held in order to overcome limitations on the level of proposed direct engagement with stakeholders. With a recent increase in cases in the country, populations have been advised and mandated by law to exercise social distancing and specifically to avoid public gatherings to prevent and reduce the risk of virus transmission. The initial draft ESSA addendum has been disclosed prior to appraisal, prior to consultations with MOH and other stakeholders on the assessment and environment and social action plans. The final document will be disclosed prior to Board approval, capturing all agreed actions and relevant time-bound achievement indicators. 16. Communities and individuals who believe that they are adversely affected as a result of a World Bank supported PforR operation, as defined by the applicable policy and procedures, may submit complaints to the existing program grievance redress mechanism or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address pertinent concerns. Affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate GRS, please visit http://www.worldbank.org/GRS. For information on how to submit complaints to the World Bank Inspection Panel, please visit http://www.inspectionpanel.org. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 8 A BACKGROUND AND SCOPE A.1 Program Description 17. An Additional Financing (AF) to the on-going under the Indonesia Emergency Response to COVID-19 Program (P173843), hereinafter referred to as the Program, is being proposed to support the Government of Indonesia (GoI) in its efforts to enable affordable and equitable access to vaccines across the country. The primary objectives of the AF are to further strengthen preparedness and response activities under the parent program and enable affordable and equitable access to COVID-19 vaccines. Given the importance of limiting the spread of COVID-19 for both health and for economic recovery, providing access to COVID-19 vaccines will be critical to improve health outcomes as well as to accelerate economic and social recovery. 18. The parent PforR, Indonesia - Emergency Response to COVID-19, was approved on May 22, 2020. The Program development objective (PDO) of the parent Program (which remains unchanged for the proposed AF) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Indonesia. Parent program includes three results areas: - Results area 1 addresses hospital and health system readiness and systemic improvements in the quality of care; - Results area 2 strengthens the GOI’s public health laboratory and surveillance systems; - Results area 3 facilitates communication and coordination for better pandemic response and preparedness. 19. The proposed AF and restructuring will finance the scale-up of Program activities and new activities that will focus on results to achieve the PDO and enhance the impact of the parent COVID-19 PforR. The existing PDO level indicators also remains unchanged, however, the target values will be updated to account for the current achievements and extended duration of the program. An additional PDO level outcome indicator will be added, on Number of persons who have received free vaccination in accordance with the prioritization plan. The summary of DLIs for the AF is presented in Annex 1. The duration of the Program would be extended from October 31, 2021 to December 31, 2022 to align with the proposed closing date of the AF loan. A.2 Program Boundary and Activities 20. Two schemes of COVID-19 vaccination are being contemplated, including the government and private. The predominant national scheme, which is supported by this Program, will be implemented by MOH and free of charge. The second scheme aimed at private employers to provide free vaccination to their employees will be led by the Ministry of State-Owned Enterprises, in partnership with MOH. The AF Program concerns with the government vaccination program. 21. The Program boundaries are aligned with the Government program, except that the Program will not finance the procurement of COVID-19 vaccines. The PforR instrument, used for the Program financing is not considered suitable to undertake the needed high-value procurement of COVID-19 vaccines, according to the World Bank guidance on processing vaccine operations. The Program will support strengthening health and vaccine deployment system in the country, including costs for consumables such as PPEs, strengthening the cold chain system, supporting operational costs of the MOH vertical hospitals, and scaling up the current response. No new construction is envisaged with this financing. 22. The AF focuses on the immediate health sector needs and represents a sub-set of the overall GoI’s emergency response to the COVID-19 outbreak. Total IBRD financing is US$750 million including US$250 million of the original financing and US$500 million from this AF. Co-financing for the AF includes Asian Infrastructure Investment Bank (AIIB) at US$500 million, Kreditanstalt fur Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 9 Wiederaufbau (KfW) at US$ 235 million, and a grant of US$ 9.9 million from Government of Australia. The AF envelope covers the costs of strengthening the country’s health system to deliver the COVID-19 vaccine safely and effectively to the target beneficiaries, scaling up the country’s capacity in its response to the pandemic, and maintaining the delivery of non-COVID essential services. 23. The program boundary has increased at MTR, fueled by the rising number of COVID-19 cases and rising budget needs for detection and treatment. In addition, the program boundary will be further augmented during this AF to accommodate: a. Continuation of the existing response in 2021 through additional budget already allocated for the MOH. This includes continued costs of COVID-19 response in the 2021 budget and line items for treatment of COVID-19 patients; incentives and compensation to human resources (HR) in the health sector for the extended period of response; and continued needs for testing supplies, PPE, and oxygen-related equipment and other line items related to the Program DLIs, as were also included in the Program boundaries for the original financing based on the 2020 budget. Accounting data on actual budget realization for 2020 have just been received, and the original boundary for 2020 will also stand updated to reflect the actual spending in 2020. b. Health system preparedness for COVID-19 vaccination such as developing policy frameworks for the safe and effective deployment of COVID-19 vaccines. This includes the establishment of policies related to best practice in vaccination; a fair and documented basis for prioritizing intra-country vaccine allocation; systems for reporting any adverse events; and the creation of accountability, grievances, and citizen and community engagement mechanisms. c. Safe and effective deployment of COVID-19 vaccines by supporting strengthened planning processes to establish guidelines and institutional frameworks and thereafter support the GOI programs to bring immunization systems and service delivery capacity to the level required to successfully deliver COVID-19 vaccines at scale. The program boundaries will also be extended to cover primary care healthcare facilities (or hereafter Puskesmas) as most of immunization services are held in these facilities. 24. The proposed AF supports the GOI in strengthening institutional readiness for the country’s COVID-19 vaccines rollout to augment its COVID-19 response. The proposed AF supports Indonesia’s planning processes to establish guidelines and institutional frameworks for safe and effective deployment of the eligible vaccines. These include: a. Development of policies for prioritizing intra-country vaccine allocations following principles established in the WHO Fair Allocation Framework; b. Establishment of a pharmacovigilance system to report adverse events on time; c. Planning to address gaps in supply chain and logistics to maintain cold chain; d. Development of a communications strategy, based on a continuous and reliable assessment of vaccine hesitancy and mitigation measures planned to improve uptake and that adequately accommodates cultural sensitivity, as well as a consultative and transparent process for decision-making on vaccine prioritization and deployment; and e. The creation of accountability, grievances, and citizen and community engagement mechanisms. 25. Given the complexity of COVID-19 vaccine deployment and system strengthening for the rollout, technical assistance closely linked to Program activities is also planned to be provided from the World Bank and its co-financing partners. This technical assistance will include support from necessary global and national expertise in implementing the COVID-19 response and vaccination program, and also support subnational authorities in effective implementation of the program. A related endeavor will be to minimize unintended consequences of the COVID-19 vaccination and Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 10 response on the overall health system performance. A key objective will be to ensure that essential, non-COVID-19 services are not disrupted by the mass vaccination efforts being added on top of a stretched health system already burdened with a continued and prolonged COVID-19 response while also grappling with subdued demand due to mobility restrictions and delays in seeking health care due to perceived risk of exposure to infection. 26. The PforR Program is not envisioned to support infrastructure investments and/or infrastructure- financing instruments for the construction and rehabilitation of healthcare facilities or cold-chain infrastructures. The PforR Program does not require infrastructure investments for the achievement of the PDO and/or DLIs. 27. The Ministry of Health (MOH) is the implementing agency of the program, with multiple implementing units responsible for different disbursement-linked indicators (DLIs), including the Director General of Health Services, Disease Control, and the Institute of Research and Development. The implementation arrangements would have to be slightly adjusted to include Ministry of Health’s immunization sub-directorate. The overall coordination responsibility remains with the Secretary General’s Bureau of Planning and Budgeting. A.3 Scope of the ESSA Addendum 28. This document is an addendum to the ESSA for the Indonesia – Emergency Financing Support for COVID-19 Program-for-Results (PforR – P173843). The scope of the ESSA addendum covers on a) implementation progress of the environmental and social plans as recommended through the original ESSA, b) assess system capacities within implementing agencies for additional activities included in the AF. 29. The addendum is being prepared to serve the following objectives: - to assess existing environmental and social capacities within implementing agencies and whether there have been improvements since the preparation of the parent PforR; - to identify relevant legislative and procedural changes since the preparation of the parent PforR and how these may impact on the PforR implementation (both the parent Program and AF); - to identify new potential environmental and social risks from the AF and; - to recommend additional measures to further strengthen the environmental and social system under the AF. 30. Similar to its parent PforR, the environmental and social risk is deemed to be substantial. There is a likelihood the Program would lead to some E&S consequences, but the risks are predictable and can be managed through risk management measures. The current strain capacity of MOH in responding to the pandemic may contribute to the possibility of the program may not achieve its E&S operational objectives or sustain the desired E&S results. Further elaboration on the rating is presented in Section F. 31. Environmental and social aspects, defined as areas of concerns, reviewed as part of this ESSA addendum cover a) population targeting, social inclusion and equity; b) public health communication and stakeholder engagement; c) individual rights to vaccination and consent, particularly amongst population groups who are sceptical and/or refuse vaccination; d) handling of grievances, including pharmacovigilance measures to monitor adverse events; e) individual data privacy; e) environmental pollution and community health and safety issue related to the handling, transportation and disposal of COVID-19 vaccine wastes (i.e. syringes, vials, PPEs, etc.); f) vaccine safety related to end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management – including rigorous cold chain control; g) Occupational Health and Safety (OHS), particularly for health workers and personnel administering vaccination. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 11 These areas of concern are aligned with the Vaccine Introduction Readiness Assessment Toom (VIRAT)/Vaccine Readiness Assessment Framework (VRAF) recommended by the World Bank, WHO and UNICEF. A.4 Approach to the ESSA 32. An environmental and social risk screening for the AF was undertaken at the concept stage (refer to Annex 4). The purpose of the screening is two-pronged. First, the screening is to confirm that there are no activities which meet the defined exclusion criteria included in the PforR in line with the Bank Guideline for the ESSA. Secondly, the screening established the initial scope of the ESSA addendum. This includes the identification of relevant systems and sub-systems under the PforR and relevant stakeholders for engagement and consultations both within MOH and external parties. 33. The ESSA addendum process was informed by the Bank Guidance on PforR Environmental and Social System Assessment (June 28, 2019). The guidance sets out core principles and planning elements used to ensure that PforR operations are designed and implemented in a manner that maximizes potential environmental and social benefits while avoiding, minimizing or mitigating environmental and social harm. 34. Following the initial screening, the system review was conducted using a two-step approach: a. Identification of relevant systems that are pertinent to the AF will be addressed in Section C on Review of Policy, Regulatory, and Institutional Frameworks; and b. Analysis of the implementation of the systems, including capacity and enforcement of certain environmental and social measures, to respond to COVID-19 crisis will be addressed in Section D. 35. An assessment of the adequacy of MOH’s operating framework in the management of environmental and social risks under the AF stocktaked on the assessment findings produced by MOH using the Vaccine Introduction Readiness Assessment Tool (VIRAT), developed by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF), which was subsequently integrated with the World Bank’s Vaccine Readiness Assessment Framework (VRAF). This was supplemented, where relevant, with reference to Good International Industry Practices (GIIP) guidelines including: a. WBG ESH guidelines on/for (i) health care facilities; (ii) waste management (iii) community health and safety; b. Center for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operation1 and; c. WHO guidelines on (i) values framework for the allocation and prioritization of COVID-19 vaccination (prepared jointly with the Strategic Advisory Group of Experts on Immunization (SAGE2); (ii) Roadmap for Prioritizing Uses of COVID-19 Vaccines in the Context of Limited Supply3, (iii) Interim Guidance on Immunization Services during COVID-194, (iv) Management of Waste from Immunization Campaign Activities5, (iv) WHO’s Interim Guideline on Health Workforce Policy and Management in the Context of the COVID-19 Pandemic Response6, (v) Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response7, (vi) WHO Vaccine Safety Events: 1 Version 2.0 issued on 29 October 2020 2 Issued on 13 September 2020 3 Issued on 3 September 2020 4 Issued on 26 March 2020 5 Issued in 2006 6 Issued on 3 December 2020 7 Issued on 16 March 2020 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 12 Managing the Communications Response8, (vii) Safe Management of Waste from Health-care Facilities9, (viii) Techincal Brief on Water, Sanitation, Hygiene and Waste Management for COVID-1910, (ix) Rational Use of Personal Protective Equipment for COVID-1911, (x) developing a national deployment and vaccination plan for COVID-19 vaccines12, (xii) How to Monitor Temperatures in the Vaccine Supply Chain13, (xiii) Aide-memoire: Infection Prevention and Control (IPC) principles and procedure for COVID-19 vaccination activities14, (xiv) WHO COVID-19 Vaccines : Safety Surveillance Manual15 36. Similar to the parent PforR, there is no single system under the ESSA. The AF is built on multiple MOH’s interventions to roll-out COVID-19 vaccination and its associated activities, including distribution and monitoring. Various systems were assessed as part of the ESSA addendum, depending on how such systems are relevant to the management of potential environmental and social risks and impacts. The assessment of the MOH’s systems for the management of environmental and social aspects considers relevant elements within the existing broader systems and selection was based on the level of potential environmental risks and impacts as well as social considerations. The assessment focuses on the adequacy of the relevant systems, including implementation, and MOH’s capacity to provide technical guidance, enforcement, and audit at the facility level. 37. The ESSA addendum enabled the identification of gaps in the documented systems and their implementation, enabling the development of specific actions for improving environmental and social performance (Section E) under the Program. The actions outline measures to address environmental and social risks and impacts, when the actions are considered complete, as well as the timeframe, responsibility and resource requirements. 8 Issued in 2013 9 2nd edition, issued in 2014 10 Issued on 3 March 2020 11 Issued on 27 February 2020 12 Issued on 16 November 2020 13 Issued on July 2015 14 Issued on 15 January 2021 15 https://apps.who.int/iris/handle/10665/338400; Published January 2021 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 13 B STAKEHOLDER ENGAGEMENT 38. This section provides a summary of the engagement activities undertaken for the PforR and specifically for the ESSA addendum, as well as future engagement activities for ESSA addendum disclosure. Stakeholder engagement will form part of the PforR implementation, particularly in multi-sectoral coordination and planning for COVID-19 vaccination, which requires a robust public health communication strategy and implementation, involving both government and non- government stakeholders at the national and sub-national levels, line ministries/agencies, sub- national governments, media, civil society organizations and communities at large. 39. Due to COVID-19 travel restrictions, virtual consultations have been held in order to overcome limitations on the level of proposed direct engagement with stakeholders. A series of consultations with MOH took place during the course of AF preparation, with external consultations being undertaken on 24th of November, 2020, 26th of November 2020, 10th May 2021, and 18th May 2021. With a recent increase in cases in the country, populations have been advised and mandated by law to exercise social distancing and specifically to avoid public gatherings to prevent and reduce the risk of virus transmission. Consultations and stakeholder feedback are an integral part of Bank operations and so rather than defer stakeholder engagement, virtual consultations have been designed to be fit for purpose. 40. Stakeholder groups consulted included relevant agencies within MOH, sub-national governments, civil society and non-government representatives and representatives relevant to the COVID-19 vaccination program. Stakeholder consultations will continue prior to the closing of the appraisal. Details of the stakeholders consulted as part of the preparation are presented in Table 1, with minutes of consultations being appended in Annex 6. Table 1: Stakeholders Consulted in the Preparation of the Program. Stakeholder Stakeholders Group Government Stakeholders Central Ministry of Health Government - Bureau of Planning - DG of Pharmaceutical Services for Medical Supplies - Directorate of Referral Services - Directorate of Primary Health Services - Bureau of Communication and Public Services - Directorate of Surveillance and Health Quarantine - Sub-directorate of Immunization - Directorate of Health Promotion - Directorate of Occupational Health and Safety - Secretary of the Board for Planning and Empowerment of Human Resource for Health - The National Institute for Health Research and Development, especially the Center for Biomedics and Health Technology Sub-national - Provincial Health Office of DKI Jakarta government - Association of Sub-national Health Offices – to be consulted Non-Government Stakeholders NGOs and CBOs - HIVOS, GWL-INA, KEBAYA, YSSfor LGBTQI - Rumah Cemara, Persaudaraan Korban NAPZA - OPSI for sex workers - IPPI, JIP for PLHIV Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 14 Stakeholder Stakeholders Group Rujak Center for Urban Studies (RCUS) - Indonesia TB Survivor Organization Association (Perhimpunan - Organisasi Pasien TB Indonesia) – to be consulted - The Alliance of Indigenous Peoples of the Archipelago (AMAN) - Nexus3 Foundation - Yaksa Pelestari Bumi Berkelanjutan (YPBB) Bandung - Greeneration Foundation & Waste4Change - PKBI Foundation Think Tank Group - Center for Indonesia's Strategic Development Initiatives (CISDI) and Watchdog - Center of Epidemiological and Surveillance Research, University of Indonesia - The National Commission on Violence Against Women (KOMNAS Perempuan) - Center on Child Protection and Wellbeing (PUSKAPA) - Kawal COVID-19 Association/ - Health Professional Associations private sector - Association of Private Health Facilities (ARSSI) – to be consulted Development - World Health Organization (WHO) partners - United Nations Children’s Fund (UNICEF) - United Nations Development Program (UNDP) - The United States Agency for International Development (USAID) - Australia’s Department of Foreign Affairs and Trade (DFAT) - Asian Infrastructure Investment Bank (AIIB) - Kreditanstalt fur Wiederaufbau (KfW) Health Facilities and Laboratories Referral Hospitals - Hospital associations – to be consulted Laboratories - Eijkman Institute – to be consulted Puskesmas - FKTP associations – to be consulted 41. Due to engagement limitations during the ESSA preparation, views of vulnerable groups were sought through engagement with advocacy groups and civil society organizations. Community views will be captured as part of the PforR implementation, particularly through the Program’s efforts to strengthen public communication, community outreach and social inclusion measures. Vulnerable groups considered under the Program include poor households, people with co- morbidities, transient or circular migrants, children and people with disabilities, and marginalized groups, including LGBTQI individuals as well as religious and ethnic minorities. Due to their respective circumstances, these groups may face access barriers to vaccination and/or receiving adequate information about the Program. 42. Stakeholder consultations and engagement will continue as part of the AF implementation. As there were engagement limitations during the preparation, environmental and social actions recommended through the ESSA addendum will be consulted continuously to relevant stakeholders during the Program implementation, including on thematic issues where resolution requires inter- agency collaboration and consensus. The initial draft ESSA addendum has been disclosed prior to appraisal and the final version will be disclosed prior to the Board approval. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 15 C POLICY, REGULATORY AND INSTITUTIONAL FRAMEWORK 43. This section provides an overview of legal and regulatory frameworks applicable for COVID-19 vaccination. An earlier legal and regulatory undertaken under the parent PforR (P173843) remains valid. Key policy and regulatory frameworks assessed include relevant policy and regulatory frameworks for COVID-19 vaccination, including review of COVID-19 vaccination guideline (to be issued by MOH). Sectoral regulations relevant for environmental and social management were reviewed as part of the parent ESSA. The addendum includes additional regulatory review relevant to the activities supported by the AF and regulatory amendment that has been undertaken since the publication of the parent ESSA. C.1 Policy, Legal and Regulatory Framework 44. The overarching legal frameworks for the handling of COVID-19 is guided by Law no. 4/1984 on Infectious Diseases, Law No. 36/2009 on Health, Law no. 2/2007 on Disaster Management and Law No.6/2018 on Health Quarantine. The GoI recently passed several guiding regulations and technical guidance in response to the pandemic. Relevant analysis of the parent ESSA remain relevant. A summary of the review of pertinent policies, laws and regulations associated with COVID-19 vaccination is presented in this subsection. Further analysis of enforcement, capacity, as well as challenges, is further elaborated in Section D. C.1.1 COVID-19 Vaccination Program 45. The objectives of the vaccination are three-pronged, including i) reducing morbidity and mortality associated with COVID-19, ii) achieving herd immunity and iii) maintaining productivity and minimizing social and economic impacts of the pandemic. Prioritization and staging of COVID-19 vaccination will weigh in these objectives, with identification of high-risk populations remaining under discussion. For the purpose of these objectives, the program will need to ensure high coverage of COVID-19 vaccination based on epidemiological characteristics and trends across the country. 46. A Presidential Regulation no. 99/202016 on Procurement and Implementation of COVID-19 Vaccines appointed MOH as the main implementer of the national COVID-19 vaccination program. Following this regulation, a number of guiding regulations have been issued. These include ministerial regulation of MOH no. 28/2020 on the implementation of COVID-19 vaccine procurement and ministerial regulation of MOH no. 84/2020 on the implementation of COVID-19 vaccination that are subsequently replaced by MOH regulation no. 10/2021. 47. Eligible vaccines are those meeting safety, quality and efficacy requirements, subject to issuance of Emergency Use Authorization (EUA) by the National Agency of Drug and Food Control (BPOM). Procurement of vaccines may start in the absence of such EUA for the purpose of securing supply. However, vaccine administration is conditional upon issuance of EUA of specific vaccines concerned. 48. Presidential Regulation no. 99/2020 defines the roles of MOH the main agency to procure, set price and implement the national COVID-19 vaccination. Under this regulatory framework, MOH is responsible for establishing a) types of vaccines and needs, with recommendation from the Committee for Handling COVID-19 and National Economic Recovery (KPCPEN); b) criteria and prioritization of population groups; c) geographic prioritization; d) vaccination schedules, and e) service standards. The regulation also clarifies the roles of other government ministries, agencies and working groups/committees, and sub-national governments. These include KPCPEN, the National Agency for Food and Drug as the main partner for pharmacovigilance, and state-owned 16 Issued on October 6th, 2020 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 16 pharmaceutical companies17 as vaccine procurement agents. Although MOH will procure and distribute vaccines, provincial and district governments will manage the operations of public health facilities and services, where vaccines will be administered. Relevant roles and responsibilities of these stakeholders are further elaborated in Table 3. 49. Through the Presidential Regulation no. 14/2021, the Presidential Regulation No. 99/2020 is amended to include provisions on termination of COVID-19 contract in the event of force majeure; transfer of legal responsibilities from COVID-19 vaccines manufactures to the government in the case the manufacturers/providers require such taking over legal responsibilities, including on aspects related to safety, quality, and efficacy of immunogenicity; the mandatory nature of COVID- 19 vaccination and administrative sanctions for people who is designated as a target recipient but does not participate in the vaccination. The other provisions under the Presidential Regulation No. 99/2020 that are not amended remain valid. 50. MOH regulation no. 28/2020 covers procurement of vaccines and their supporting instruments (e.g. syringes, PPEs, cold chain, etc.), as well as their distribution to delivery points. In implementing the vaccination program, MOH can establish partnerships with external stakeholders, including the private sector (i.e. logistics, storage, distribution, etc.). A technical working group has also been established to provide advisory services and oversight. 51. MOH regulation No. 10/2021 regarding the COVID-19 vaccination implementation issued on 25 February 2021, replacing the previously issued regulation no. 84/2021. This regulation aims to provide guidance for central government, provincial government, district/city government, community and other stakeholders on the implementation of COVID-19 vaccination in the country. It covers provisions on: a) COVID-19 vaccines planning assessment, b) vaccines target recipients, c) distribution of vaccines and other supporting equipment and logistics, d) COVID-19 vaccines delivery, e) cooperation on COVID-19 vaccination implementation, f) Adverse Events following Immunization (AEFI) monitoring, g) communication strategy, h) monitoring and reporting, i) budgeting, and j) supervision. 52. MOH Director General of Disease Prevention and Control further issued technical guidance on COVID-19 vaccination implementation through decree no. HK.02.02/4/1/2021. The guidanceprovide further details on the roll-out of COVID-19 vaccination in the country and cover aspects such as planning, target recipients, budgeting, distribution of vaccines and other supporting logistics, vaccination implementation, cooperation, monitoring and reporting, monitoring of AEFI, communication strategy and evaluation. 53. Further regulatory analysis concerning relevant themes considered under the ESSA addendum is presented in the following sub-sections. C.1.2 Prioritization and Allocation 54. The president announced on 16th of December 2020 that every Indonesian citizen is entitled to free COVID-19 vaccines. To do so, the GoI is committed to securing a multi-year financing of 2.4 billion for COVID-19 vaccination over the span of 3.5 years. 55. Despite global efforts to develop safe and effective vaccines and ramp up production capacity, the initial vaccine supply will likely be limited in its initial years of roll-out. Allocation into specific target groups takes into account the following factors, including prioritization to meet vaccination objectives, limited supplies, administration capacities, the current degree of uncertainty related to age-independent vaccine efficacy and safety for certain population groups (i.e. the elderly and people with co-morbidities). 17 These include PT. Bio Farma and its subsidiaries, including PT. Kimia Farma Tbk and PT Indonesia Farma Tbk Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 17 56. Frontline health workers have received priority allocation, following issuance of EUA by BPOM. Phase 2 of the vaccination targeted essential public service officers as well as the elderly. Initial roll out has relied on SinoVac manufactured by SinoVac Biotech (hereafter SinoVac). Additional types of vaccines, including AstraZeneca, have also been reported to have been distributed, with more brands being expected to be more readily available in the near future. While there has been a shift from the initial focus on economic recovery to protection of the vulnerable groups to reduce mortality and morbidity, there is a lack of clarity on the correlations between evidence-based allocation to achieve the vaccination objective with the actual allocation, which appears to prioritize the former (i.e., economic recovery). Table 2: GoI Planned Allocation of COVID-19 Vaccination Population Group Number % of Total of Target Population Beneficia ries (millions) First Wave Vaccination Period January–May 2021 Phase 1 Health personnel. Vaccination will be conducted 1.5 0.65 for health personnel in 34 provinces. This includes health assistants, support/administrative personnel, and students who are currently in professional training who also work in health service facilities. Phase 2 a Public service workers. Frontline public service 17.3 6.44 providers, including teachers and other educational institution staff; military and police forces; other uniformed officers; judicial officers; strategic public service officers; those working at ports of entry, transportation stations, banks, utilities including electric/power companies, and clean water companies; and other officers involved in directly providing services to the community. Phase 2 b Senior citizens: 60 years old and above 21.5 8.00 Second Vaccination Period June 2021–March 2022 Wave Phase 3 Vulnerable population based on geographical 63.9 23.66 location, social, and economic aspects Phase 4 Wider population; economic actors using a cluster 77.4 28.66 approach according to the availability of vaccines C.1.3 Targetting 57. For the initial phase of vaccination, identification of target and prioritized populations was developed top-down by the Central Government with technical considerations from the KPC-PEN, responsible to lead the overall planning and operational measures to respond to COVID-19 emergency. This relies on the existing population databases, including those administered by MOH (Information System on Health Human Resources/SISDMK), BPJS Health (PBI JKN recipients), BPJS Employment, Ministry of Home Affair’s population and civil registration database (Dukcapil SIAK), institutional databases from the Military and Police Forces. These multiple datasets have been consolidated into the One Data Information System for COVID-19 Vaccination (Sistem Informasi Satu Data Vaksinasi COVID-19). The Ministry of Communication and Information is responsible to inform target beneficiaries using an “SMS Blast� platform through identifi ed phone Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 18 numbers, in partnership with telecommunication providers. However, there is no available guidance pertaining to reconciling data inconsistencies and discrepancies. In anticipation of exclusion and inclusion errors in the central registry, the draft technical guideline for COVID-19 vaccination has incorporated a bottom-up vaccine registration mechanism. However, such a mechanism requires NIK an eligibility criteria, which can potentially exclude individuals without NIKs. C.1.4 Hazardous Waste Management 58. The potential wastes generated from COVID-19 vaccination, including waste from vaccination activities (e.g. used syringes, vials, PPEs, etc.), are considered as hazardous wastes under the country’s applicable hazardous waste regimes. Government Regulation No.101/2014 on Hazardous waste management casts the country’s main hazardous waste management framework, while the MOEF Regulation No. 56/2015 on Hazardous Waste Management from healthcare facilities outlines the specific requirements on the management of hazardous medical wastes from all healthcare facilities, including from hospitals and puskesmas. These regulations specify relevant standards for medical waste management – including the requirements to reduce, reuse and recycle, as well as requirements of their packaging, storage, transportation, treatment and disposal, which are consistent with the GIIP18. The requirements under these regulations were built upon a “cradle to grave� principle with a rigid manifest system to track the flow of waste s from the generator to the disposal facility.19 The requirements prescribed under the government regulations are applied not only to the vaccination activities, but also to the distribution of the vaccines. The management of wastes that could possibly generated from the distribution activities, both conducted by private or public sector, are required to follow the guideline and standard as prescribed in the regulations. 59. Managing hazardous wastes also forms part of the accreditations requirements for hospitals and Puskesmas. MOH regulation No. 34/2017 on Hospitals accreditation outlines the requirements for hospitals accreditation, in which the performance standards are further defined in the National Standards for Hospital Accreditation (SNARS), whereas the MOH Regulation No. 46/2015 outlines the requirements for primary healthcare facilities accreditation. Both accreditations require hospitals and Puskemas to manage their hazardous waste through sets of criteria which are in accordance to the GIIP20. Through the on-going Supporting Primary Health Care Reform PforR (I-SPHERE – P164277), the implementation of primary healthcare accreditation system is being enchanced, including to support the facilities in managing their hazardous wastes. 60. In managing waste generated from COVID-19 response, MOH issued a guideline on the management of COVID-19 wastes in healthcare facilities through the issuance of Ministry of Health Decree No. HK.01.07/MENKES/537/2020 pertaining medical waste management from healthcare and quarantine facilities. Similar guidance has also been provided by Ministry of Environment and Forestry (MOEF) through the issuance of circular letter No. SE.2/MENLHK/PSLB3/PLB.3/3/2020 on infectious (hazardous) and domestic waste management from COVID-19 response. Both guidances provide discretionary measures which allows healthcare facilities to use their existing treatment facilities (e.g. incinerators or autoclaves) although the said equipment have not received licensed from MOEF and disposal of wastes in burial pits for facilities without onsite treatment 18 GIIP includes WBG General EHS Guideline: Waste Management, WBG EHS Guideline for Healthcare facilities and WHO safe management of wastes from health-care facilities 19The newly issued Governmental Regulation No. 22/2021 on the Implementation of Environmental Protection and Management amended several articles in the Government Regulation No. 101/2021 on Hazardous Waste Management. The changes are mostly on permitting procedures for hazardous waste facilities and did not change the technical requirements in managing the hazardous waste. 20 GIIP includes WBG General EHS Guideline: Waste Management, WBG EHS Guideline for Healthcare facilities and WHO safe management of wastes from health-care facilities Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 19 facilities or access to third-party waste handling–especially for the ones located in rural area. The guideline also provide technical standards that has to be met for these alternative measures. 61. Guidance on the management of wastes generated from general immunization activities is outlined in the MOH Regulation No. 12/2017 on Immunization implementation. The regulation provides detailed guidance on the treatment/processing of vaccination-related wastes such as used syringes, vials, and PPEs). A specific guideline on COVID-19 vaccination waste has also been included in the technical guideline on COVID-19 vaccination services that was issued by MOH.21 The technical guideline outlines the requirements on managing infectious and non-infectious waste that will be generated during COVID-19 vaccination including used syringes, vials, PPEs, etc. It provides alternatives in managing the waste such as through incineration/non-incineration method (autoclave/microwave), licensed third-party contracts, and burial. The technical guideline is primarily adopting the waste management approaches as prescribed in MOH Regulation No. 12/2017. 62. In ramping up the logistical support for waste management during the COVID-19 vaccination campaign, Presidential Regulation No. 99/2020 on Procurement and implementation of COVID-19 vaccines has also identified the needs to provide supporting equipment such as safety boxes to stored used syringes before further treatement or disposal. C.1.5 Occupational Health and Safety 63. The country’s OHS regulation regime consists of a comprehensive set of regulations to govern this aspect, such as Law No. 36/2009 on Health (section XII) and Government Regulation (PP) No. 50/2012 on Health and Safety Management, which required hospitals and other health care facilities to oversee and ensure the workers’safety and health by implementing an OHS management system. Specific guideline on how to implement the management system in a hospital setting are prescribed in MOH regulation No. 66/2016 on Hospital's occupational health and safety. These regulations applied to both private and public healthcare facilities. In addition to the country’s overarching OHS law and government regulations, OHS requirements in healthcare settings are also outlined in the hospitals and puskesmas accreditation criteria. COVID-19 Infection Prevention and Control (IPC) guideline22 has been issued by MOH to provide advice for various stakeholders in managing the pandemic, including in healthcare settings. A specific health protocol for COVID-19 IPC in healthcare facilities, including private and public hospitals and puskesmas, has also been issued by MOH through Decree No HK.01.07/MENKES/1591/2020. The protocol includes the needs to provide regular health screening for healthcare workers (including supporting personnel), PPEs, and IPC training, as well as set the maximum working hours for healthcare workers. 64. COVID-19 vaccination can be administered in hospitals, clinics, Puskesmas and health posts at ports of entry. Only facilities meeting GOI’s requirements for vaccination can administer COVID- 19 vaccination, including a) availability of personnel, b) availability of cold chains suitable to specific requirements of vaccine types, c) valid operational license. MOH’s technical guideline for COVID-19 vaccination also introduced several measures pertaining to OHS requirements during vaccine administration. These include a) priority vaccination for those administering vaccination, including supporting personnel; b) application of health and basic hygiene protocols, and use of PPEs, c) social distancing requirements, d) fatigue management by capping daily quotas. 21 Directorate General of Disease Prevention and Control Decree No. HK 02.02/4/1/2021, issued January 2, 2021. 22 5th Revision, issued on 13th July 2020 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 20 65. Through the Presidential Regulation No. 99/2020, GoI has also identified PPEs as one of the supporting equipment that need to be procured and provided to healthcare facilities for the vaccination campaign. C.1.6 Public Health and Safety, including Patient Consent 66. While patient rights are protected by law (i.e., the Indonesian’s Constitution (Article 1) and Laws (Law on Health Articles 4 – 8, Law on Hospitals No. 44/2009, Article 2, Article 43), patients’ consent requirements can be waived under emergency situations in the interest of public safety (Law on Health no. 36/2009, Article 56 – 58 and Law on Health Quarantine no. 6/2018). 67. The Presidential Regulation no. 14/2021 was promulgated to enforce COVID-19 vaccination in Indonesia. Relevant provisions include: a. Articles 13A and 13B: persons designated by MOH’s data collection and listed as target recipients of the vaccine are required to participate in the vaccination, unless they do not meet the criteria for receiving the vaccine as per the indications for the available vaccine. b. Anyone who is designated as a target recipient who does not participate in the vaccination, may be subject to administrative sanctions in the form of: • postponement/termination of social security/social assistance); suspension or termination of government administration services; and or fines. • In addition to the above, anyone who is a target recipient and does not participate in the vaccination and causes obstruction to the implementation and prevention of the spread of COVID-19 may be subject to – in addition to the administrative sanctions above – sanctions in accordance with the law on infectious disease outbreaks. 68. MoH Regulation No. 10 of 2021 on vaccination for the handling of COVID-19 pandemic serves as an implementing regulation of the above Presidential Regulations (14 of 2021). The MoH Regulation provides that the eligibility of COVID-19 recipient will be determined based on the available vaccine indications and based on the assessments of the Indonesian Technical Advisory Group on Immunization and/or Strategic Advisory Group of Experts on Immunization of the World Health Organization (SAGE WHO). This MoH Regulation further provides that in carrying out its data collection and determination of the COVID-19 Vaccine target recipients, the data on target recipient that would be collected in the Government’s One Date COVID-19 Vaccination Information System shall be prepared “based on the criteria of COVID-19 Vaccine recipient and the target’s willingness to receive the COVID-19 Vaccine, which contains the name and address (by name and by address), as well as personal identification number [of the target].� The MoH Regulation clarifies how MoH is to cooperate with other institutions in implementing COVID-19 vaccination, including with subnational governments includes: (a) support through the provision of healthcare workers; (b) sites for vaccination; (c) logistic/transportation; (d) warehouse and vaccine storage; (e) safety; (f) socialization and community mobilization; (g) provision in non-healthcare worker and (h) medical waste management. Subnational governments, i.e., provincial governors and city/municipality regent/mayors are required, along with MoH, to coordinate the implementation of COVID-19 vaccination at every stage, including preparation, implementation and monitoring and evaluation implemented within their respective regions. 69. In line with the Presidential Regulation no.14/2021, the MOH Regulation no.10/2021 makes reference to administrative sanctions since a lower level regulation cannot contradict a corresponding higher-level regulation. However, the MoH regulation does not provide further details on the actual amounts and modalities for administrative sanctions. As currently there is no technical manual and/or operational guidance to implement such administrative sanctions, enforcement of these measures is considered highly unlikely in the absence of such documents. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 21 Further, it contains a provision to provide for target populations’ willingness to be registered to the GoI’s vaccination program (Article 13). 70. In summary, these regulations specific to COVID-19 vaccination: (i) require the Ministry of Health (MoH) to collect personal data to identify COVID-19 Vaccine target recipients, and in doing so, requires the collection of said personal data to be based on the target’s willingness to receive the COVID-19 Vaccine; (ii) provides for an exemption from vaccination if the target recipient does not meet the criteria for receiving the vaccine as per the indications for the available vaccine; (iii) provides the possibility to impose administrative sanctions on target vaccine recipients who refuse to be vaccinated; and (iv) provides the possibility to impose criminal sanctions on target vaccine recipients who refuse to be vaccinated and cause an impediment to the handling of the spread of COVID-19, cross-referencing to a 1984 Infectious Disease Law. 71. Apart from the above-referenced Regulations, there are no general laws on vaccination, though the 2009 Health Law provides the basic right of access to healthcare, and two laws, the 1984 Infectious Disease Law and the 2018 Health Quarantine Law, have been referenced as sources prescribing criminal sanctions for refusal to be vaccinated (the 1984 Infectious Disease Law in particular was referred in the specific Presidential decree no.14/2021 on COVID-19 Vaccination). At present, there seems to be only one known case during the last 37 years where any criminal sanctions (under both the 1984 Infectious Disease Law and the 2018 Health Quarantine Law) have been sought against an individual, and this was not in the context of the individual refusing to be vaccinated. There are also no known cases where the Government imposed administrative sanctions for those refusing to be vaccinated. A provincial regulation from DKI Jakarta province (No. 2 of 2020) is the only known regulation at the subnational level that provides for a IDR 5 million (or about US$ 330) fine for every person “who deliberately refuse[s] to receive treatment [for COVID-19] and/or COVID-19 Vaccination.� 72. Given the history and on the basis of the current legal framework, whether any sanctions are enforceable is still a matter of debate and it is unclear whether such sanctions will be enforced. The COVID-19 vaccination manual as stipulated in the Minister of Health’s decree no. 01.07/Menkes/4638/2021 does not provide any instructions on the application of administrative sanctions and other punitive measures under the GOI’s vaccination program. As of to date, the ESSA addendum could not confirm other relevant legal measures to enforce the sanctions as envisaged in the Presidential Regulation. Further, media reports suggest that there is also a commitment by the government to the House of Representatives (DPR) Committee IX that vaccination will not be forced. 73. Based on the above assessment, the risk of use of force for those not accepting vaccination is perceived to be very low. This residual risk is mitigated through covenants in the legal agreements as well as the Program action plan. As per the provisions applicable to the World Bank’s Multiphase Programmatic Approach under which this Program is financed, use of force represents a key limitation to what the World Bank can finance. Mitigating actions in the Program Action Plan that support the avoidance of force include the provisions for strong public communications to support a primarily persuasive approach, the provisions for a Feedback and Grievance Response Mechanisms (FGRM), and provisions to inform health workers and patients around the medical code of ethics and for respectful behavior towards patients. 74. In the event of Adverse Events following Immunization or AEFI (Kejadian Ikutan Paska Imunisasi or hereafter KIPI), ministerial regulation of MOH no. 12/2017 on Immunization provides an overarching framework for the handling of KIPI. The regulation requires the establishment of independent committees at the national and sub-national levels by the minister of MOH and governors respectively to undertake KIPI surveillance and investigation. These committees are staffed by medical specialists, including paediatricians, internists, obygns, neurologists, forensics, pharmacologists, immunologists, vaccinologists and other personnel from relevant sectors. MOH’s COVID-19 vaccination guideline includes relevant procedures for KIPI surveillance and reporting. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 22 Patients are eligible for medication and treatments during the investigation and causality analysis of KIPI and additional treatments if reported cases are vaccination-related. The regulation does not further elaborate whether patients are eligible for additional compensation. 75. Under the Presidential Regulation no.14/2021, the government takes over legal responsibilities for providing COVID-19 vaccines, including on aspects related to safety, quality, and efficacy of immunogenicity if the manufacturers/providers require such taking over of legal responsibilities. Taking over of legal responsibility is granted up to the revocation of the health emergency, and if there are cases of adverse events following vaccination where the vaccination was carried out or vaccines were procured before the revocation of the health emergency, the government still takes over legal responsibilities. Financial compensations will be provided to cases leading to fatalities and/or permanent disabilities, with further details, including amounts to be regulated by the Ministry of Finance. In parallel, there is also a provision for free treatment of any complications arising out of COVID-19 vaccination, which is included in the MOH guidance. 76. In the event of KIPI, healthcare workers cannot be sued by any legal means in the context of emergency for life-saving treatments (Law on Health no.36/2009, Article 58, point 2). This may result in lack of ability for patients and families to charge medical professionals for malpractices leading to injury, disabilities or even deaths under the criminal code (Kitab Undang-Undang Hukum Pidana). Medical negligence and litigation implicating medical professionals (doctors and dentists) are investigated by the Indonesian Medical Disciplinary Board (Majelis Kehormatan Disiplin Kedokteran Indonesia/MKDKI). The MKDKI is an autonomous body of the Indonesian Medical Council (KKI) and is authorized to issue testimony/statements with regards to negligence or mistakes or ethical issues in medical practices as well as remedial measures necessary including sanctions. Under these circumstances, the use of civil code (Kitab Undang-Undang Hukum Perdata) may be pursued, and complaints may be settled through financial compensation for improper services. C.1.7 Feedback and Grievance Mechanism 77. Public service accountability includes citizens’ rights to provide feedback and file grievances. Such rights are protected by law. Law no. 25/2009 on Public Service governs the interactions, expectations, rights, responsibilities, and discretions between all parties involved in public service delivery, including end users and service providers. In 2008, the GoI issued Law no. 4/2008 on Access to Public Information which affirms citizens’ access to information from government organizations, including State-Owned Enterprises (SOEs). The Law also specifies types of disclosable information and procedures to obtain such information. 78. Most vaccinations will likely be administered at primary healthcare centers (or hereafter Puskesmas). By law, Puskesmas needs to establish service agreements with the communities in their respective jurisdictions on the basis of which they operate (Ministerial Regulation of MOH no. 46/2015). Such service agreements will define minimum service standards, including operating hours, codes of conduct, complaint-handling mechanisms, etc. MoH’s commitments to enhance public health accountability is reflected in their Health Strategic Plan (Rencana Strategis or hereafter Renstra) where Puskesmas’ performance targets include responsiveness to public feedback and complaints. The on-going PforR on Supporting Primary Health Care Reform (I-SPHERE – P164277) supports MoH in strengthening MoH’s primary healthcare accreditation system, where two of the agreed enhancement measures include disclosure of grievance records by Puskesmas to enhance transparency and accreditation system strengthening in assessing FGRM performance at the facility level. 79. Due to various uncertainties related to public health risks associated with COVID-19 vaccination, enhancement in public health service accountability, particularly through bottom-up processes to promote citizens’ participation in the overall delivery of COVID-19 vaccination will be critical. Such efforts are expected to strengthen pharmacovigilance measures that the AF is supporting. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 23 C.1.8 Data and privacy 80. Protection of civil rights to privacy and private data is fragmented across regulations and no overarching law in existence for the purpose, with weak protection of individual rights to personal data23. Indonesia has 32 laws and regulations which govern the protection of personal data/ privacy. No single comprehensive law is in place for the protection of private data, which in some circumstances results in abuse of private data collected through Banking transactions and social media for commercial purposes, with risks of fraudulent appropriation of personal data for criminal conducts. The Bill on Private Data Protection, which consolidates citizens’ rights to data protection and privacy, is pending approval from Parliament. This represents a gap in the regulatory framework. 81. For the purpose of COVID-19 surveillance, MOH’s Centre of Data and Information (Pusdatin) is leading the development of an electronic platform integrating Tracking COVID-19 application with Allrecords TC 19, with the former serving as a dashboard to MOH management and the latter serving as a data entry platform. A protocol for data protection measures has been drafted, including a measure to encrypt individual data points. The tracking application, including data storage and protection, is oversighted by the State Cyber and Code Agency (BSSN). Implementation of such data protection measures remain to be observed. 82. Under the AF, a guideline for personal data protection for the purpose of COVID-19 vaccination has been developed by the MOH’s Pusdatin. Pusdatin has adopted ISO 27001 on Information Security Management where relevant measures such as Smart Checking to allow access to only authorized officers and Non-disclosure Agreement (NDA) have been in place. Since COVID-19 vaccine data entry points will mostly be located at the sub-national level, the existing guideline on data protection will need to be further operationalized to include relevant measures in the event of breach, violation to the integrity pacts, and data leakages at data entry points. C.2 Institutional Responsibilities 83. MOH is the proposed implementing agency for the AF with the overall coordination responsibility in the Secretary General’s Bureau of Planning and Budgetting. The Program will be implemented by multiple directorat generals within MOH, responsible for achievement of agreed Disbursement Linked Indicators (DLIs). These include the Director Generals of Health Services, Disease Control, the Health Human Resource Board, and the Institute of Research and Development. 84. In defining relevant recommendations for environmental and social enhancement measures under the AF, relevant stakeholders were identified as part of the ESSA addendum. Within the Program boundaries, such recommendations are focused on MOH as the implementing agency for the AF. For the purpose of the assessment, key stakeholders are categorized as follows (refer Table 3): a. Category 1: Implementing stakeholders within MOH. Program Action Plans (PAPs) will be recommended to these stakeholders. b. Category 2: External stakeholders contributing to the management of the environmental and social aspects of the PforR. Collaboration and engagement will be sought as part of the AF preparation and implementation. 23Six of those are related to health sector include Law No 29/2004 on Medical Practice, Law No 36/2009 on Health, Law No 44/2009 on Hospital, Law No 18/2014 on Mental Health, and Law No 35/2009 on Narcotics. Article 57 (2) of Law, No 36/2009 on health, stated that exception on data protection could be made in several conditions include for public health interest by respecting the necessity and proportionality principles. Furthermore, Minister of Health Regulation No. 269/MenKes/Per/III/2008 on Medical Records stated that all health facilities must maintain the confidentiality of the patient’s medical records except for extraordinary circumstances for health and safety reasons, law enforcement, at the request of the patient(s) concerned, and for research and education purpose without disclosing the patient’s identity. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 24 c. Category 3: Broader stakeholders involved in the implementation of COVID-19 vaccination (GoI’s Program), where the PforR is part of. Engagement and information sharing will be sought with these stakeholders during PforR implementation. 85. The proposed AF institutional arrangement takes cognizance of Indonesia’s decentralized government system and hence, the focus will be placed on facilities where MOH has direct influence and control. 86. While broader risks were assessed under the ESSA addendum, PforR action plans (PAPs) for the environment and social management were intended for relevant departments within MOH responsible for Program implementation (i.e., stakeholders under Category 1). 87. The following table provides a summary of the institutional responsibilities with respect to the GoI’s COVID-19 vaccination and how they are related to the proposed AF. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 25 Table 3: Institutional Responsibilities for Environmental and Social Performance Institutions Institutional Responsibilities in the GoI led COVID-19 Institutional Responsibilities in PforR Emergency Response Category 1: Implementing Stakeholders within the Program Ministry of Finance - Setting policies on budget allocation and re-allocation for - Signatory of the loan agreement COVID-19 emergency response - Provision of financing to achieve agreed DLIs - Overall monitoring of COVID-19 emergency response spending Secretary General of - Provide strategic direction and guidance for COVID-19 vaccine - Chair the Program Steering Committee, including liaising MOH coordination; communication and coordination at the Echelon 1 level (Directorate Generals/DGs); - Provide technical inputs to the national emergency response (COVID-19 hadling) as a member of the task force COVID-19 - Lead coordination with relevant departments within MoH handling and National Economic Recovery Program. and external ministries/agencies. Bureau of Planning of - Coordinate planning of COVID-19 vaccination including - Lead the program coordinating unit in the MOH developing cost estimates for the vaccine procurement, and its implementation of the PforR; related operational and logistic requirements; - Ensure availability of information required to monitor - Develop a budget workplan covering allocation of financial PforR implementation; resources across relevant directorates within MoH; - Undertake requisite supervision and reporting during - Liaise with the Ministry of Finance (MoF) on budget allocation. PforR implementation. Center of Health Data - Integrate information systems related to pandemic response; - Provide overall monitoring of COVID-19 pandemic and and Information government response, including COVID-19 vaccine roll- - Lead the development of a COVID-19 situation data platform; (Pusdatin) of MOH out; - Develop manuals for information collection, including quality - Develop a dashboard for internal MOH/Government, assurance, data protection and confidentiality. including for the broader public. Center for Health - Revise the Health Sector Pandemic Operation Plan based on - Monitor the implementation and deployment of PPE for Crisis of MOH inputs and comments from the Intra-Action Review (IAR); the purpose of COVID-19 vaccination. - Develop a Personal Protective Equipment (PPE) plan for COVID-19 vaccination, including need estimates and a deployment plan Directorate General of - Ensure availability of pharmaceuticals and health equipment for - Lead procurement of COVID-19 vaccines and logistical Pharmaceutical COVID-19 response, such as cold chains logistical support (i.e. support in collaboration with other relevant government entities; Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 26 Services for Medical automatic voltage stabilizers (AVS), standby generators, safety - Liaise with the National Agency of Drug and Food Supplies of MOH boxes, etc.); Control (BPOM) for pharmacovigilance and Halal - certification. Bureau of - Public health communication on healthy behaviour, preventive - Public risk communication on COVID-19 vaccine related Communication and measures, vaccine related issues, etc.; issues (i.e. effectiveness, post-vaccination adverse events, Public Services of etc.); - Handling of grievances (submitted through Halo Kemkes). MOH - Monitor public acceptance of COVID-19 vaccination (pre- and post- roll out); - Provide counter-measures to address misinformation and hoaxes related to COVID-19 response, including COVID-19 vaccination. Directorate of Referral - Provide quality assurance, technical guidance and supervision - Oversee implementation of COVID-19 vaccination at Services of MOH of health care facilities (i.e. hospitals). health care facilities (i.e. hospitals). Directorate of Primary - Provide quality assurance, technical guidance and supervision - Integrate implementation of a COVID-19 vaccine Health Services of of primary health care facilities (Puskesmas). program to the existing national immunization program MOH and administer COVID-19 vaccination at the primary healthcare facilities; - Lead a Cold Chain Equipment Management (CCEM), including inventory of cold chain equipment; - Provide regular reporting and recording of immunization services. Directorate of - Lead identification, targeting and tracing of COVID-19 cases; - Lead surveillance activities, including scale up; Surveillance and - Conduct a country readiness assessment for COVID-19 - Lead the development of a vaccine implementation Health Quarantine of vaccination roll-out (under the available instruments); roadmap; MOH - Develop a country-level COVID-19 vaccine - Lead technical dialogues with technical departments and roadmap/implementation plan; development partners/counterparts; - Lead coordination with technical departments and related - Participate in the development and strengthening of the stakeholders for COVID-19 vaccine provision and national pandemic preparedness plan. implementation; - Ensure availability and reliability of COVID-19 surveillance information. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 27 Sub-directorate of - Implement national vaccine programs including the COVID-19 - Implement the national COVID-19 vaccination program Immunization of vaccination campaign. Its responsibilities include: a) produce MOH and disseminate technical guidance, b) estimate the needs and costs for COVID-19 vaccines and related supplies, assesses and plans for Cold Chain Equipment (CCE including ultra cold chain if needed), and c) estimate the size of human resources and its training; ensure quality assurance; and provides supervision and monitoring and evaluation. Directorate of Health - Lead public health communication and campaign on healthy - Lead public health campaign on healthy behaviour and Promotion of MOH behaviors and be in charge of the development of behavioural COVID-19 vaccination (i.e. efficacy, side effects, etc.) change communication manuals. Directorate of - Provide technical guidance/procedure in managing wastes from - Liase with MOEF and Directorates of Referral and Environmental Health COVID-19 vaccination activities in healtcare facilities Primary Health Services in the provisions of advice and of MOH guidance on the implementation of hazardous waste - Ensure the implementation of waste management measures to management of COVID-19 vaccine wastes across protect frontline health workers that include professional health hospitals and healthcare facilities. workers, administrative and other supporting staff at health facilities (mortuary personnel, laundry, cleaning service) Secretary of the Board - Manage the database of frontline Human Resource for Health - Maintain frontline HRH databaseas the priority groups for Planning and (HRH) including medical and non-medical support staff for COVID-19 vaccination; Empowerment of responsible for COVID-19 response; - Monitor vaccine acceptance and pharmacovigilance for Human Resource for - Implement an incentive scheme and death compensation frontline HRH. Health (Badan payments for health workers. PPSDM) of MOH The National Institute - Provide technical guidance/standards for medical and public - Maintain database on the reporting of confirmatory for Health Research health laboratories, both public and private, and ensure the testing for COVID-19 and Development quality in providing COVID-19 related services, including but - Monitor the implementation of the external quality (NIHRD), especially not limited to confirmatory testing, and genome sequencing, assurance (EQA) the Center for - Implement the external quality assurance framework to all Biomedics and Health - Monitor the implementation of the genome sequencing laboratories in the network Technology - Monitor the involvement of the Ministry of Health in the global efforts to track COVID-19 variants Category 2: External Stakeholders Contributing to Environmental and Social Management for the AF Committee for - Lead the overall planning and operational measures to respond - Issue regulations for COVID-19 vaccine implementation Handling COVID-19 to COVID-19 emergency and National Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 28 Economic Recovery - Serve as a policy maker for COVID-19 vaccine (KPCPEN) distribution schemes; - Integrate population data for vaccination targeting across existing sources from line ministries/agencies, including MoH, BPJS, MoCI, and public authorities whose personnel are designated as priority recipients (i.e. the Military, Police Force, law enforcement agencies, Ministry of Education, etc.) The National Agency - Supervise pre- and post-distribution of COVID-19 drugs - Issue an Emergency Use Authorization (EUA) which of Drug and Food serves as a vaccine distribution permit; Control (BPOM) - Supervise pre- and post-distribution of COVID-19 vaccines; - Provide Halal certification assurance of COVID-19 vaccines; - Undertake pharmacovigilance services (i.e. collection, detection, assessment, monitoring, and prevention of adverse effects with COVID-19 vaccines) The National Disaster - Lead the overall national planning and operational measures to - Chair the national COVID-19 Taskforce Management respond to COVID-19 emergency - Provide strategic direction, Authority (BNPB) Ministry of Home - Sub-national government coordination, including with village - Sub-national government coordination Affairs (MoHA) governments - Provision of population databases - Population Administration Information System (Sistem Informasi Administrasi Kependudukan or hereafter SIAK Presidential Staff - Monitor and manage grievance and complaints redress related - Coordinate public communication on COVID-19 Office (Kantor Staff to Covid19 vaccination via LAPOR platform vaccination; Presiden) - Designate focal point(s) for the implementation of COVID-19 vaccination; Ombudsman - Receive and investigate grievance related to the administration - Grievance management of Covid19 vaccination Ministry of - Provide technical and regulatory guidance on the management - Provide guidance and advice on COVID-19 vaccination Environment and of COVID-19 related waste to healthcare facitilites, related waste management Forestry transporters, and processing facilities Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 29 - Liase with MOH in providing advice and guidance on the implementation of hazardous waste management during COVID-19 to healthcare facilities Ministry of - Develop population wide communication of the program - Handle information dissemination under the One Data for Communication and COVID Vaccination, including public outreach - Develop an individual reminder system (SMS Blast) Information (MoCI) - Monitor and countermeasures misinformation regarding - Develop a registration system as a part of the One Data for the COVID-19 vaccines Vaccination Program National - Serve as the government auditing agency - Serve as a verification agency for the PforR, including Government’s the AF Finance and Development Monitoring Agency (BPKP) Category 3: Broader Stakeholders Involved in COVID-19 Vaccination Program Indonesian Technical - Provide technical advice on government immunization - Provide inputs to the GOI on the prioritization and choice Advisory Group on program including COVID-19 vaccination of vaccines Immunization (ITAGI) Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 30 D INSTITUTIONAL CAPACITY AND PERFORMANCE ASSESSMENT 88. This section summarises key findings or gaps on the assessment of system implementation, including the capacity of the relevant institutions to effectively implement the environmental and social management systems in the parent PforR and additional systems described in the AF. Institutional capacity and performance were reviewed in reference to the on-going parent PforR implementation as well as the government immunization program, and how these will be calibrated to tackle the pandemic. D.1 Implementation of Environmental and Social Action Plans of the Parent PforR 89. The progress towards achievement of the PDO and overall implementation progress were rated Satisfactory in the last Implementation Status and Results report as of August 23, 2020, and good progress was recorded during the mid-term review (MTR) conducted in October 2020. Amidst a pandemic that continues to progress, the GOI has scaled up its infrastructure and interventions to respond to COVID-19. For example, testing capacity for COVID-19 using Polymerase Chain Reactions (PCR) tests, considered the gold standard method for diagnostic testing, went up from around 3,000 tests per day in April 2020, to more than 70,000 tests per day by the end of October 2020 (MTR report 2020). Notable progress on implementation of agreed environmental and social action plans under the Parent PforR, with several areas for improvements. A summary of relevant achievement is presented in this section, with further details being appended in Annex 3. 90. On infection control and medical waste management: technical guidelines and/or strategy for infection control in relation occupational health and safety (OHS) and medical waste management at various health facilities along with relevant virtual training/coaching to health facilities and health workers have been conducted. The MOH has issued an appointment letter (Surat Keputusan) for the designated MOH’s team to provide oversight on the management of medical wastes at healthcare facilities. A rapid assessment on medical waste practices and capacity has also been conducted. The mission team suggests the rapid assessment to cover wider respondents as COVID- 19 healthcare facilities network has been expanding, and to provide disaggregated information by types of facility. MOH has also ramped up the waste management capacity in several provinces by distributing additional four autoclaves and four incinerators. The provision and deployment of Personal Protective Equipment (PPE), as a part of the infection control has followed the World Health Organization (WHO) recommended demand forecast tool, the Essential Supplies Forecasting Tool (ESFT), combined with a logistical distribution monitoring platform that are managed by the Center for Health Crisis. In order to protect health workers, the guideline on priority testing, not only to health workers but also health facility staff has been issued. 91. On public risk communication, patient safety and personal data protection: the integration of data protection measures in the surveillance protocol is currently on-going under the All Record Track COVID-19 platform and being implemented under the oversight from the State Cyber and Code Agency (Badan Siber dan Sandi Negara - BSSN). A public health campaign and communication strategy have been developed by MOH to support public awareness related to COVID-19 but it still requires tailored delivery measures to reach vulnerable groups, including people with disabilities and with low literacy. Such a strategy will also need to incorporate social stigma countermeasures through public awareness and education. An existing Feedback Grievance Redress Mechanism (FGRM) has been in operation and is processing feedback and complaints, although its level of effectiveness needs to be further assessed through a systematic analysis of available grievance records. Also functioning is the mechanism for patients’ safety and security, which follows the national patient safety framework from the National Commission for Patient Safety ( Komite Nasional untuk Keselamatan Pasien – KNKP).The MOH needs to enhance these existing systems through availability of relevant information about grievance channels and their management, Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 31 particularly to anticipate a surge of demands as a result of COVID-19 vaccination roll out. Areas to be considered include inter-sectoral and governmental coordination for grievance settlement, design and strategy public risk communication, as well as accessibility and visibility of these systems. D.2 COVID-19 Vaccination Program 92. Indonesia’s massive, free COVID-19 vaccination program covering all of the 181.5 million adults in the country represents a major undertaking of an unprecented scale. Achieving what is called “herd� immunity will require vaccinating a large proportion of population all at once. Vaccinating adults is much more complex than infants, especially when it may involve multiple doses which will add complexities of targeting and monitoring. The latest Indonesian Basic Health Survey reported that the proportion of fully immunized children was 58 percent, and 63 percent of all unvaccinated children were living in rural areas. As much as a three-fold difference in immunization coverage rates exist across provinces, and sizeable inequalities by economic status exist as well. An intense focus on expanding immunization capacity will therefore be required, and Indonesia must ensure that its health system can effectively implement a comprehensive, inclusive (and sustainable) COVID-19 vaccine deployment strategy. 93. COVID-19 vaccination being supported by the AF will be implemented by the same PIU for the parent PforR, which will remain coordinated by MOH’s Bureau of Planning. MOH has prepared a roadmap on COVID-19 vaccine implementation that includes a) prioritization on geographical coverage and population groups, implementation phases and timeline; b) implementation arrangement; c) system capacity assessment, including cold chains for vaccine distribution. A technical guideline on COVID-19 vaccination services has also been developed through a decree of Directorate General of Disease Prevention and Control No. HK 02.02/4/1/2021 to provide direction and practical guidance on the preparation, implementation, surveillance, as well as monitoring and evaluation of the program. At this stage of preparation, MOH is commissioning an assessment of vaccination readiness across delivery points in the country through a self-assessment undertaken by each District and/or Municipal Health Offices. BPJS-operated Primary Care Application (or hereafter P-Care) will be used as a platform to record and consolidate assessment findings on the basis of which planning decisions will be made. The same application will also be used to track implementation of COVID-19 vaccination at each delivery point. 94. Given the coverage of COVID-19 vaccination and anticipated demand, the GoI has adopted measures to secure vaccines from several sourcesTable 44). Indonesia has signed an agreement on COVID-19 vaccine procurement under the GAVI COVAX facility, which assures free vaccines for 20 percent of the country’s population. Furthermore, the GoI has undertaken bilateral negotations with potential suppliers from China, United States (US), and United Kingdom. Indonesia’s vaccine strategy will need to rely on vaccines that do no require ultra-cold supply chains. These include whole vaccine, viral vector vaccine and sub-unit vaccines, rather than mRNA- based vaccines. Table 4: GoI’s Vaccine Procurement Plan (source: MOH - Updated) National plan target COVAX grant Other sources Specific vaccines and (population, %) sourcing plans Stage 1 (0.65) 0 1,500,000 Sinovac, bilateral Stage 2a (6.44) 6,000,000 3,440,000 Free COVAX, Sinovac, bilateral Stage 2b (8.0) 5,000,000 Free COVAX, Sinovac, bilateral Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 32 Stage 3 (23.66) 20,000,000 43,900,000 Free COVAX, Astra Zeneca, paid COVAX, Sinovac, Novavax Stage 4 (28.66) 28,000,000 49,400,000 Free COVAX,Astra Zeneca, paid COVAX, Sinovac, Novavax 95. As of the date the ESSA addendum the GoI has rolled-out its vaccination program in the second phase, having completed the first phase targeting 1.5 million frontline healthworkers across all provinces, with exemptions and exclusions for those with specified medical conditions, recent COVID-19 infection and pregnant women among them, and having achieved a 93 percent full vaccination rate in this group. EUA for SinoVac was released by BPOM on 11th of January 2021. On the same date, Indonesia Ulema Council (Majelis Ulama Indonesia or hereafter MUI) issued a halal certification for SinoVac. The second phase of vaccination has also been rolled out and is currently ongoing with Sinovac and COVAX vaccines (Astra Zeneca, which has also received BPOM authorization), targeting public service workers and the elderly, approximately 17.3 and 21.5 million respectively. 96. Although procurement and distribution of vaccines will be centralized, vaccination will be administered by provincial and district governments across their respective public health facilities and services. Further, a smaller parallel program for employers intending to self-finance and provide free vaccination for their employees, though not part of this Program, will also be available in due course. Management capacity and commitments to immunization greatly vary across different provinces and/or districts, leading to varying immunization coverage rates. While almost two-thirds (67 percent) of Puskesmas offer daily or weekly immunization services and 92 percent provide outreach services on a monthly basis, budget constraints for last-mile distribution services represent a barrier. Almost three-fourths of all vaccinated children in Indonesia receive their immunization at a sub-village level health post (Posyandus), followed by 10 percent at Puskesmas, 10 percent at private clinics and hospitals (although this can be as high as 50 percent in some provinces), and the remainder at a delivery village post (Polindes) and other places (including midwives’ homes). These patterns reflect sheer challenges of vaccine delivery, which may affect availability and accessibility of COVID-19 vaccines in rural and lagging regions. mRNA-based vaccines, requiring ultra-cold chains, may not be readily be available in these regions. 97. As COVID-19 vaccination is being rolled out, adaptive management to accommodate different scenarios based on the latest scientific evidence about the efficacy, safety and logistical requirements of potential vaccines as well as the latest epidemiological data on the characteristics of COVID-19 infection and/or transmission across Indonesia will be critical. Further, since the majority of available and candidate vaccines will likely require double doses, the government also needs to develop a mechanism for follow-up and compliance monitoring to prevent attrition. There is a likelihood that there will be more than one type of vaccine being administered. Therefore, while a detailed arrangement of who administers, where and to whom each type of vaccine is dispensed has been recently developed in the COVID-19 vaccination guideline, the overall administration capacities remain to be observed, and will likely be stretched due to the scale and speed, and complexity of COVID-19 vaccination. 98. A national COVID-19 vaccination will require close cooperation with line ministries/agencies, sub- national governments, private entities, civil society organizations and communities at large. Further, an inclusive public communication strategy combined with a robust mechanism for oversight, including pharmacovigilance supported by a clear accountability framework to monitor adverse events and accessible and credible Feedback and Grievance Redress Mechanisms (FGRMs) will serve as critical platforms to support public health risk oversight and promote vaccine uptake going forward. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 33 D.3 Environmental and Social Considerations 99. Further analysis of relevant capacities and environmental and social considerations corresponding to the areas of concerns is provided in the following sub-sections. The assessment was undertaken based on GoI’s existing capacity in the overall immunization Program and recent gains through COVID-19 emergency response. D.3.1 Allocation and Prioritization 100. Vaccines are being planned and ordered for free vaccination of all adults in Indonesia, making it one of the frontrunner middle income countries of its size in doing so. Vaccine prioritization in Indonesia is generally aligned with the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and Indonesian Technical Advisory Group on Immunization (ITAGI – refer Table 5). As indicated in the technical guideline for COVID-19 vaccination, vaccination seeks to focus on reduction of direct morbidity and mortality and maintenance of most critical services, while considering reciprocity towards groups that have been placed at disproportionate risks to mitigate consequences of this pandemic (i.e. frontline health workers and public service officials). The government is taking a cautious approach of balancing the needs to inoculate the elderly and people with comorbidities to reduce deaths with the known safety and efficacy of procured vaccines. Although the initial plan was to prioritize adults of 18-59 years old to reach herd immunity among the more active members of the population more quickly, it was recognized that there was unclear evidence that vaccines can reduce transmission, and that this plan might not result in herd immunity. There are about 181.5 million people to be vaccinated (or 67 percent of the population), requiring 426 million doses of vaccines with a double-dose regimen and 15 percent wastage rate (Reuters January 4th, 2021). Indonesia has secured 125.5 million doses of China’s SinoVac vaccines, 108 million doses from the free COVAX supply and 50 million doses each of Astra Zeneca and Novavax vaccines, with another 50-100 million doses being requested from the paid COVAX option. Table 5: Vaccine Prioritization Stage WHO SAGE recommendation for GOI Prioritization Community Transmission Stage 1 (very - 1a. Health workers at high to High risk health workers at very high limited vaccine very high risk of acquiring and risk of acquiring and transmitting availability for transmiting infection infection. These include frontline 1-10 percent of - 1.b. Older adults defined by age- healthworkers and supporting staff, national based risk specific to medical students interning at health population country/region facilities (Actual. timeline January – February 2021) Stage II - Older adults not covered in Stage - Public service workers, including (limited 1 the military, law enforcement and vaccine - Group with comorbidities public service personnel, including availability for determined to be at significantly those providing transportation, 11-20 percent higher risk of severe disease or banking, electricity, water services of national death. Efforts should be made to and other personnel directly population ensure equity to disadvantaged involved in providing public groups services; - The elderly (60 years old and above), subject to the availability of safe vaccine for the age group. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 34 Socio-demographic groups at - (Ongoing; estimated timeline significantly higher risk of February – June 2021) severe disease or death24 - Health workers engaged in immunization delivery (routine program and COVID-19 - High priority teachers and school staff Stage III - Remaining teachers and school Vulnerable groups due to geospatial, (moderate staff socio-economic factors vaccine - Other essential workers outside (Est. timeline June 2021 – March availability for health and education sectors (i.e. 2022 21-50 percent police officers, municipal of national services, child-care providers, population agriculture and food workers, transportation workers, government workers essential to critical functioning of the state not covered by other categories) - Pregnant women - Health workers at low to moderate risk of acquiring and transmitting infection - Personnel needed for vaccine production and other high-risk laboratory staff - Social/employment groups at elevated risk of acquiring and transmitting infection because of inability and/or lack of ability to exercise physical distancing Stage 4 N/A The broader public and other economic actors not included above (based on vaccine availability) (Est. timeline October 2021 – March 2022 D.3.2 Population Targeting and Exclusion 101. As scientific evidence for COVID-19 vaccines is evolving rapidly and new COVID-19 variants are being identified, there exists significant uncertainty and unknowns regarding the efficacy, effectiveness, and safety of existing and potential vaccines, especially against the emerging variants. In the light of evolving evidence, it is important for the government to prepare for different scenarios of prioritization based on the most current scientific results of the vaccines' safety, efficacy, and effectiveness as well as their availability. This includes preparing databases and rosters of eligible 24This will depend on country context, examples may include: disadvantaged or persecuted ethnic, racial, gender, and religious groups and sexual minorities; people living with disabilities; people living in extreme poverty, homeless and those living in informal settlements or urban slums; low- income migrant workers; refugees, internally displaced persons, asylum seekers, populations in conflict settings or those affected by humanitarian emergencies, vulnerable migrants in irregular situations; nomadic populations; and hard-to-reach population groups such as those in rural and remote areas (WHO SAGE) Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 35 and prioritized individuals under different scenarios. For example, if a candidate vaccine is declared safe and effective for elderly and/or people with comorbidities, with adequate and early preparation, the government could quickly identify and locate individuals belonging to these categories. In the future, when vaccines are deemed safe and effective for children, adolescents and/or pregnant mothers, the government will be well prepared to administer vaccines to these subpopulations. Such capacities are yet to be tested as COVID-19 vaccination is being rolled out. 102. The first batches of vaccines had been prioritized for healthcare workers (1.5 million), public administration, and law enforcement officials, and other essential workers in close contact with the society at large. The elderly have also received prioritization in the ongoing second phase of vaccination. For these sub-population groups, the government will rely on their centralized databases such as SISDMK (Health Human Resource Information System/Sistem Informasi Sumber Daya Manusia Kesehatan) as well as civil registry databases. However, the GoI needs to make sure that these databases are updated through coordination with respective sub-national governments. This also includes modalities for covering sub-populations who are not included in the civil registry databases. Further, MOH’s COVID-19 technical guideline does not further specify vulnerable sub- groups, particularly those considered as vulnerable, disadvantaged, underserved and/or impacted beyond socio-economic dimensions and how to identify these groups. 103. There are several existing specialized databases such as MoHA Population Administration Information System (Sistem Informasi Administrasi Kependudukan or hereafter SIAK), Ministry of Social Affairs (MoSA) Unified Database for Social Protection (Data Terpadu Kesejahteraan Sosial or hereafter DTKS), Universal Health Coverage (Jaminan Kesehatan Nasional or hereafter JKN) register administered by BPJS, and various logbooks at Puskesmas and hospitals, each with different sets of information. These datasets are being consolidated into One Data Information System for COVID-19 Vaccination for the purpose of targeting and allocation. However, since there are likely inherent inconsistencies and potential errors in these data sources, vaccination database will likely carry over these inconsistencies and errors. Further, there are risks of fragmentation and misallocation since actual implementation will be decentralized, potentially relying on various population datasets. 104. People who are not part of any government’s registries or whose domicile do not match their administrative records may be excluded. This population may include, but not limited to, circular or seasonal migrants, homeless people and street children, transgender population, and isolated populations. Since the transmission is disproportionately high in urban areas, certain urban populations might also be inadvertedly excluded from targeting and identification due to mismatch between their actual residential address and their administrative records. They include people living in informal settlements, newly arrived migrants who have not updated their administrative record, as well as seasonal and transient migrants (including migrant students). Other transient populations such transgender, homeless, and street children may even be missing from any governmental databases. 105. The new draft of Ministerial Technical Guidance on COVID19 Vaccination will require the Civil Identification Number (NIK) as a pre-condition for vaccination, following guidance from the anti- corruption commission for due accountability for the use of vaccines25. While NIK coverage has expanded up to 95 percent of adult population (above 17 years old), such a requirement may potentially prevent up to 4.9 million adults in Indonesia from being inoculated (SUSENAS 2019). Analysis of the National Socio-Economic Survey (SUSENAS) data and various studies show that populations without NIK are more likely among the poorest and living in underserved regions such as Papua and Maluku. They are also more likely to be coming from vulnerable groups such as 25 https://voi.id/en/news/25909/kpk-kirim-tim-untuk-tata-kelola-vaksin-covid-19 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 36 people with disabilities, transgender, transient seasonal migrants, and indigenous communities who face structural and legal barriers to acquiring NIK and legal documentations. Instead of making NIK a prerequisite, vaccination programs and posts could be used as an entry point to identify and outreach those without NIK and facilitate their civil registration. The MOH is exploring such modalities to retain the requisite accountability against misuse of vaccines while also ensuring inclusive mechanisms to identify and register beneficiaries and this is also being included in the Program action plan (PAP). 106. Measures to address exclusion errors are therefore critical understanding that there are likely loop holes in the existing One Data Information System for COVID-19 Vaccination. Such measures will need to be responsive and agile to inform vaccination planning due to limited availability of vaccines in the near and medium-term. KOMINFO and MOH is deploying Short Message Service (SMS) notification to target participants through which they can register (Health Minister's Decree No.HK.01.07/Menkes/12757/2020). Such registration is expected to be undertaken as early as possible to assess demand in particular localities to inform vaccination planning and quotas. The functioning of this system is yet to be observed as it is being expanded to include other target participants beyond health workers. 107. A bottom-up database updating can also be activated by mobilising village apparatus/hamlets (i.e. RT/RW), village supervisory non-commissioned officers (Babinsa) and community cadres to update their registry at village or RT/RW level and/or the nearest Puskesmas. MoHA or provincial/district governments could initiate such updating by providing villages or RT/RW with an initial list of all individuals recorded to reside in specific areas from their databases (especially from SIAK). The updating should be inclusive, and it should register all individuals residing in their authority regardless of the stated domicile on their ID card (or the lack thereof). 26the Anti- corruption Commission (KPK) found that 16.7 million individuals without NIK were registered in MoSA’s DTKS, reflecting the significant discrepancies across government databases. Although the updating is a basic responsibility of the village and RT/RW apparatus, it is usually conducted in a passive manner (through the so-called LAMPID form), that is waiting for individuals to report to the village office. For vaccination roll-out, the government needs to mobilise village and RT/RW staff to actively update the registry, by registering new-borns and newcomers, and removing dead and out-migrants from their lists. An active updation is not a new task as recently villages and RT/RW were also deployed to update the register for eligible beneficiaries for government social assistance as part of COVID-19 response. 108. In circumstances where there is a discrepancy between government’s consolidated roster of prioritized individuals with the actual number of people needing vaccination, a mechanism is yet to be established to reconcile the exclusion errors. The exclusion of eligible individuals could emerge not only from missing individual data but due to people’s mobility between provinces or districts/cities. When an individual is administratively registered in one province but residing in another province, there are risks that they would not be able to access vaccination. Therefore, it is necessary to build a system where eligible individuals who are missing from both local and national registers could come forward and immediately be provided with the necessary vaccines. This may also require allocating extra vaccines to buffer against unaccounted additional needs as well as wastage. 26 CNN Indonesia. 2021. “Temukan Masalah, KPK Pastikan Pantau Penyaluran Bansos.� Nasional, January 6, Online edition, sec. National. https://www.cnnindonesia.com/nasional/20210105204309-12-589911/temukan-masalah-kpk- pastikan-pantau-penyaluran-bansos. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 37 109. Furthermore, in case where vaccine hesitancy and/or refusal is still prevalent, and as vaccine supply improves in the future, there are possibilities of significant number of eligible individuals not showing up for vaccination. There needs a contingency measure to enable vaccine re-allocation to the next prioritized individuals to prevent expiration and/or other illegitimate misuse. D.3.3 Equity and Accessibility 110. Free COVID-19 vaccination is technically available for every Indonesian citizen above 18 years of age, prioritizing those at high risks of acquiring and transmitting infection, or suffering from disproportionate morbidity and/or mortality due to COVID-19, with an objective to achieve herd immunity. 111. In addition to vaccine availability challenges and how the prioritization plan will work in practice, access inequity also stems from public safety considerations, logistical distribution constraints, health system readiness especially in lagging regions and exclusion from population databases. Individuals with certain medical conditions (i.e. severe co-morbidities), persons with recent COVID-19 infection and pregnant women are provided medical exemptions, for which detailed screening protocols are already provided in the Technical Guidelines of the MOH27,28. Access issues, such as where the health system itself is under-developed, can also create an equity challenge, particularly in lagging areas. Greater emphasis on understanding such access challenges and finding solutions to improve access to vaccines will be needed to ensure equity in vaccine access. 112. Distance to health facility can deter people living in areas where health facilities are scarcely placed from accessing vaccination. In these areas, a passive vaccination approach where individuals must travel a great distance to health facilities may incur a considerable transportation cost on the individuals that further deter them from getting vaccinated. People with disabilities especially with physical mobility challenges, including elderly, may confront accessibility issue even if distance to health facility is not a problem. It is therefore important to devise a plan to outreach these populations. 113. Cost may also be an issue not only in regards to transportation to health facility but also pertaining necessary test as part of vaccination screening requirement. PLHIV for instance need to take additional CD4 count test to be eligible for vaccination while people with comorbidities are encouraged to consult medical doctors before getting vaccination. Combined with the lack of testing facilities and accessibility issues, this may further incur cost and disincentivize people to be vaccinated. It is essential to facilitate prerequisite screening tests that are accessible and at an affordable cost, to ensure both the accessibility and safety of the vaccination. Individuals and communities who need specific screening test could be directed to certain facilities where they can access the required tests as well as vaccinations. 114. Understanding equity in access greatly rely on availability of documentation to enable systematic tracking and gap filling. Historically, administrative data on immunization are generally weak, with inconsistencies in administrative and survey data (up to 30 – 40 percentage points). Data are often distorted in transmission, with heavy reliance on reporting from delivery points, starting at the community level (Posyandu, Polindes) and use of different denominators across reporting levels. 27 https://promkes.kemkes.go.id/sk-dirjen-nomor-hk0202412021-tentang-petunjuk-teknis-pelaksanaan-vaksinasi-dalam-rangka-penanggulangan- pandemi-covid19 28 https://covid19.go.id/masyarakat-umum/kelompok-lansia-komorbid-penyintas-covid-19-dan-ibu-menyusui-bisa-divaksinasi-ini-syaratnya Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 38 Further, data are often handled manually, through a fragmented nature of MOH’s information system components, leading to poor intake and quality of reporting due to administrative burdens. D.3.4 Public Health Communication 115. There are studies that suggest a significant number of people were hesitant to be vaccinated for reasons that can be considered as healthy scepticisms pertaining to the safety and efficacy of COVID-19 vaccines (Harapan et al. 2020, Indonesia High-frequency Monitoring of COVID-19 Impacts, WHO, UNICEF, ITAGI, MOH 2020). However, other reasons are reportedly to be founded on religious grounds. Further, scepticism around the existence of the virus may be fuelled by hoaxes and misinformation circulating in the media and the broader public. MOH has prepared a communication strategy as part of COVID-19 emergency response. However, its effectiveness is likely hampered by such hoaxes and misinformation, often exacerbated by changing policies, resulting in scepticism and public confusion. Furthermore, as there is little evidence that any COVID-19 vaccines will reduce infection and transmission, public communication regarding vaccines should include transparent message about what vaccines can and cannot do to prevent false sense of security among vaccinated individuals. Amid such potential public hesitation, the public communication strategy should adopt persuasive approaches to foster demand to the extent possible and hence, enable individuals to provide their consent prior to vaccination. An assessment of MOH’s public health communication effectiveness is currently not available. Previous massive campaigns for vaccination have been done in the past as well, even though not at the scale COVID- 19 vaccination requires. Indonesia has held Immunization Weeks (Pekan Imunisasi Nasional) as the GOI made mass immunization into a national movement that requires the involvement of and contribution from all. There have been several massive campaigns including the successful one to eradicate Polio (in late 90s) and more recently the local or regional mass immunization campaign to address outbreaks of vaccine-preventable diseases (Measles outbreaks and Diphtheria outbreaks in 2017 -2018). Public communications and education have been a critical component in these campaigns, and will also be important in the COVID-19 vaccination program. While there is an increasing trend of vaccine hesitancy to child immunization program in the country, especially in some geographical pockets that are known to have high(er) vaccine resistance or hesitancy, the GOI has adopted persuasive approach and modify the communication material to address identified factors of vaccine resistance or hesitancy. In this regard, there are news items quoting higher officials, even the President, that GoI is emphasizing primarily on a persuasive approach for COVID-19 vaccination as well.29 Clear messages on the safety and effectiveness of the government- funded vaccines will be critical to foster and sustain demand as the GOI is planning a national roll- out. 116. MOH needs to assess the above risk and seek public and individual buy-in through keeping the public informed. Therefore, based on the risk assessment, MOH must also build a communication strategy to educate and assure citizens, to engage mass media and religious leaders, and to solicit citizens' feedback. Such a strategy is lined with VRAF and VIRAT criteria about demand-creation for vaccination. The public communication strategy needs to include means for citizens to access updated information on the vaccines in an accessible manner, to be informed of the delivery service standards (on progress), to ask questions, convey concerns, and receive official responses in a prompt and credible manner. MOH also needs to provide a clear message on what COVID-19 vaccines can and cannot do based on available scientific evidence so as to not give false sense of security. 29 https://www.cnnindonesia.com/nasional/20210215132153-20-606363/fadjroel-jokowi-persuasif-dan-humanis-dalam-vaksinasi-covid Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 39 117. An accessible public complaint and grievance mechanism should also be set up and be informed to the public. Transparency requires measures to communicate with the public openly, clearly, accurately, and straightforwardly about the allocation, including any changes and modifications made during implementation. Specific strategies for communication with people with unique needs such as blind people, deaf, and children are required to ensure they receive the correct information. In addition, several categories of population (e.g PLHIV, people with comorbidities) may also need additional information due to specific health risks and concerns as well as their needs to take additional tests as part of the vaccination screening process. 118. At this moment, HALO Kemkes along with COVID-19 Hotline 119 have been the main channels within MoH through which members of the public could actively seek information and education regarding vaccines and vaccination plans. A team of 11 personnel have been mobilized for the call center. Additional training and reference materials are necessary to prepare agents to answer public queries and to refer other questions to the right sub-division(s) within MoH. Furthermore, MoH needs to strengthen coordination between relevant sectors as well as to establish a clear disposition protocol and pathways with other sectors and Health Offices at provincial and district/municipal levels. The protocol will include clarifying the types of complaints and queries that need to be expedited or to be diverted to other divisions in MoH or other institutions, or to be transferred to subnational units. D.2.4 Hazardous waste management 119. Persistent disparity between hazardus medical waste volume and the processing capacity in the country remains the biggest challenge in managing COVID-19 related waste in Indonesia, especially in the regions outside Java. According to MOEF ,30 a total of 1,662.75 tons of COVID- 19 medical waste has been generated as of October 15, 2020. The total medical waste generated in the country has spiked around 30 percent, from 293.87 tons/day before the pandemic to currently around 382.03 tons/day from around 2,820 hospitals and 9,884 puskesmas in the country. Although the processing capacity has also been increased over the course of the pandemic,31 the additional capacities are mainly concentrated in Java. There are currently about 110 hospitals with licensed incinerators or autoclaves with the total processing capacity of 70.21 tons/day and 17 licensed third- party medical waste-processing facilities–more than half of these facilities are located in Java.32 The uneven presence of licensed medical waste facilities in Indonesia indicate areas of attention for the planning of additional facilities or alternatives for medical waste management. Similar circumstance is also observed in the distribution of licensed hazardous waste transporters, with 97 out of 140 licensed transporters are located in Java. The uneven distribution of the processing facilities and transporters is hindering the optimum implementation of medical waste management in the country. Based on the distribution and availability of medical waste processing facilities in Indonesia, it is evident that the waste processing facilities in the country are currently dominated by the use of incinerators. There are recommendations from several stakeholders on the use of other non- 30Based on presentation by Environment and Forestry Ministry Director General for Waste Management presentation during National Appeal on Accelerating Medical Waste Management on November 13, 2020. The event was posted in MOH’s Environmental Health website (http://kesling.kesmas.kemkes.go.id/videodetail/detail/43), accessed on November 19, 2020. 31Based on data from MOH, there were 82 licensed incinerators and 3 licensed autoclaves across 20 out of 34 provinces as of Dec 2019 with total capacity around 53.12 tons/day and 12 third-party processing facility with total capacity of up to 248.88 tons/day. The data presented during Medical Waste Management During COVID-19 Pandemic Webinar which was organized by Indonesia Hospital Association on April 1, 2020. 32Information on licensed incinerators and autoclaves were based on MOEF data in April 2020, while the information on licensed thirdparty were based on MOEF data in October 2020. Both information were obtained in the opening presentation during National Appeal on Accelerating Medical Waste Management on November 13, 2020. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 40 incineration technology, such as autoclaves, in managing the surge of medical wastes.33 Similar recommendations are also shared by several stakeholders during ESSA consultation. Figure 1. Distribution of medical waste processing facilities and transporters 120. In a bid to further increase the processing capacity, MOH has distributed additional four incinerators and four autoclaves to seven provinces in September 202034, while MOEF is also constructing five additional medical waste treatement facilities.35 A roadmap to further increase hazardous waste processing capacity has also been prepared with a total of 32 incinerators are planned to be built across the country36. To tackle the surge of medical waste during the pandemic and limited availability of processing facility, MOH and MOEF provided alternatives methods through the issuance of COVID-19 waste management guideline, which allows healthcare facilities to use their existing incinerators or autoclaves although the said equipments have not received licensed from MOEF. Discretionary measures for COVID-19 wastes disposal in burial pits are also allowed for facilities without incinerators, autoclaves or access to third-party waste handling–especially for the ones located in rural area. These discretionary measures are subjected to certain technical requirements37 and coordination with the provincial- and/or district-level environmental agencies. 33Ministry of National Development Planning (Bappenas) and Environmental Engineering Alumni Truss Institute of Technology Bandung (2020), “Pengelolaan Limbah B3 Medis & Sampah Rumah Tangga Penanganan COVID -19�, Policy Brief. Ismawati, Y., Septiono, M.A., Paramita, D. (2021). “ Pengelolaan Limbah B3 Medis di Indonesia dan pada Masa Pandemi�. Nexus3 Foundation 34WHO, in collaboration of UNDP, procured the incinerators and autoclaves (WHO COVID-19 situation report – 26, dated September 23, 2020). MOH through Directorate of Environmental Health coordinated the distribution of these equipments. The seven provinces are West Sumatra, DKI Jakarta, Central Java, Yogyakarta, East Java, Bali, and South Kalimantan. 35Based on presentation by Environment and Forestry Ministry Director General for Waste Management presentation during National Appeal on Accelerating Medical Waste Management on November 13, 2020. The five provinces are Aceh, West Sumatera, South Kalimantan, West Nusa Tenggara, and East Nusa Tenggara 36MOEF Pers Statement No.SP. 204/HUMAS/PP/HMS.3/5/2020 “KLHK Perkuat Regional untuk Respon Limbah Infeksius COVID-19�, online, accessed on November 20, 2020, http://ppid.menlhk.go.id/siaran_pers/browse/2477. MOEF(2018), “Peta Jalan (Roadmap) Pengelolaan Limbah Fasilitas Pelayanan Kesehatan (Fasyankes)�, Jakarta. 37The requirements for incinerators and onsite burial pits are specified in MOEF Regulation No. 56/2015 and the COVID-19 waste management guidelines issued by MOEF and MOH. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 41 121. Despite these efforts, there are public concerns on the suboptimal management of COVID-19 wastes that could lead to improper disposal of the said waste–-highlighting the importance of continuous support, supervision and enforcement.38 The enforcement/supervision on waste management practices in Indonesia is carried out by the Provincial/District/Municipal Environment Agency. As part of an efforts to enhance coordination with the local environmental agency, MOEF issued circular letter no. S.401/PSLB3/PS/PLB.0/10/2020, reemphasizing the importance of supervision from local governments to ensure all medical waste are processed in accordance to applicable regulations and guidelines. MOH and MOEF have jointly organized training sessions39 on COVID- 19 medical waste management for healthcare facilities (including hospitals and puskesmas), Provincial/ District/ Municipal Environment Agencies and Provincial/District/ Municipal Environment Health Agencies, covering all 34 provinces in the country. 122. It is expected that there will be an increase of medical waste volume from COVID-19 vaccination activities that could add more burden to the now-strained medical waste management system. MOH predicted that there are potentially about 7,579 tonnes of additional medical waste generated during COVID-19 vaccination campaigns.40 Through the technical guideline on vaccination services, MOH provide guidance for healthcare facilities in mannging the wastes generated during the vaccination program. MOH, through the Environmental Health Directorate, has also held a socialization on COVID-19 vaccination waste management.41 Training and socialization should also be conducted in regular basis, targeting not only hospitals and Puskesmas but also local environment and health agencies. Continous coorperation and coordination between MOEF, MOH and local environment and health agencies are also imperative for the effective management of medical waste in the country. D.3.5 Occupational Health and Safety (OHS) 123. While the country has a regulatory framework and guidelines on OHS and IPC in place, the current strained capacity in the healthcare system is challenging its optimal implementation. Particular concerns are raised related to the availability of PPE for healthcare workers, in which the limited supply might potentially exposed the workers to COVID-19 infection.42 During the COVID-19 response, MOH used a forecasting tool developed by WHO – Essential Supplies Forecasting Tool (ESFT) to assess the PPEs needs across the country. The tools calculate the needs based on the spread and growth of the infection. A logistic dashboard to track the distribution has also been developed and in operation. The government has also worked with local industries to ramp up the PPE supply, with a significant increase in availability of local masks, gloves, and gowns reported since February 2020.43 The implementation of COVID-19 vaccination will require additional PPE supplies for the healthcare workers and other personnel involved in the vaccination program. Logistical planning for vaccination considers the needs to assess and procure PPEs as prescribed in MOH’s technical guideline for COVID-19 vaccination implementation. 38BBC News Indonesia, “Virus corona: Limbah infeksius Covid-19 masih ditemukan di TPA, 'ada kelonggaran, pengabaian, dan tidak ada pengawasan'�, online, accessed on November 24, 2020, https://www.bbc.com/indonesia/majalah-54640725 39 A total of 17 sessions have been conducted between 22 June to 15 July 2020, with 15,360 audiences attended the training. 40Based on presentation by Director of Environmental Health during the Socialization of COVID-19 vaccination waste management om January 13 & 14, 2021. The event was posted in MOH’s Environmental Health Channel (https://www.youtube.com/watch?v=dXz8KshdsLA), accessed on January 15, 2021 41 Socialization of COVID-19 vaccination waste management om January 13 & 14, 2021 42 Jakarta Post, “Most nurses died of COVID-19 were stationed in patient rooms�, online, accessed on December 10, 2020, https://www.thejakartapost.com/news/2020/12/06/most-nurses-who-died-of-covid-19-were-stationed-in-patient-rooms-ppni.html 43 MOH, “Ketersediaan obat pasien COVID-19 terjamin di semua provinsi�, online, accessed on November 24, 2020, https://www.kemkes.go.id/article/view/20092300001/ketersediaan-obat-pasien-covid-19-terjamin-di-semua-provinsi.html Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 42 124. MOH has developed training modules for healthcare personnel who will be involved in the vaccination program. Such training is aimed to upskill relevant healthworkers in implementing the vaccination program, including safe administration of COVID-19 vaccination, IPC measures, adverse event surveillance, etc. The training program has started since November 2020. As of January 13th 2020, a total of 23,016 healthcare personnel have attended the training, spread 44 all 34 provinces.45 125. Healthcare workers have been identified as one of the priority groups to receive COVID-19 vaccines. Based on the country’s COVID-19 vaccination roadmap, a total of 1,48 million healthcare workers in 34 provinces are the first in line to receive vaccination over the period of January to April 2021. Such prioritization is in accordance with the WHO SAGE recommendation, which is expected to provide protection to these workers as frontliners. However, since pregnant women and people with severe morbidities are currently excluded, efforts to promote safe-working conditions for healthworkers under these categories should be maintained. 126. A maximum daily quota has been established under the COVID-19 technical guideline. This is expected to minimize disruption to other health services during the vaccination program and prevent influxes of people which present public health risks. Such daily quotas will also help avoid the already long work hours and overwork, leading to fatigue, which is one of the concerns that has been raised over the course of the pandemic. D.3.6 Public Health and Safety related to Vaccine Quality and End-to-End Supply Chains and Logistics Management Systems 127. Logistic management system, including cold chain infrastructure and equipment, is critical to maintain vaccines quality from the time they are being manufactured to the point of administration. MOH Regulation no. 12/2017 on Imunization Implementation outlines the types of cold chain infrastructure and equipment needed at the provincial, district and facility levels, as well as the mandates for each stakeholder in the planning and implementation of the vaccination program. The regulation divides the cold chain infrastructures into three catagories: 1) Storage (e.g. cold room with temperature between 2° to 8°C, freeze room with temperature between -25° to -15°C, etc.); 2) transportation (e.g. cold box, cool pack, etc.); and 3) temperature monitoring (e.g thermometer, thermograph, etc.), and also provide overall guidance on its planning (capacity assessment), financing, and distribution. Requirements on the standard operation and regular maintenance for each of the cold chain equipments are also set in the regulation. 128. Vaccine and logistical distribution will be monitored through an electronic system for logistics monitoring called SMILE (Sistem Monitoring Imunisasi dan Logistik Secara Elektronik). The AF seeks to enhance GoI’s logistic management system by upgrading the cold chain system required to meet the globally accepted quality standards including remote temperature monitoring deployed in the vaccine cold chain storage and distribution as per cold chain upgradation plan, including the introduction of track and trace technologies (GPS-enabled monitoring in select locations). 129. MOH in coordination with Provincial and District/Municipal Health Offices is currently assessing the existing cold-storage facilities, their quality and specifications, as well as distribution across regions. This will inform requisite logistical requirements as part of COVID-19 vaccination planning. Additional logistics have been entrusted to a State-owned Enterprise (SOE), BioFarma which will use hired capacity from other pharmaceutical SOEs and companies, such as Unilever. 45Data taken from Directorate of Immunization Services presentation on COVID-19 vaccination program implementation, presented on January 14, 2020. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 43 No infrastructure is being built under the government program and not under the World Bank's financing. As of December 2019, routine vaccinations take up 35 percent of the current total cold storage capacities. 65 percent is estimated to be available and accommodate both regular and COVID-19 vaccination until 2021. It is expected that the GoI will procure additional 449 refrigerator units in 2020 and 1028 units in 2021. MOH is currently assessing the country’s cold chain with technical support from the Clinton Health Access Initiative (CHAI). As of January 2021, a total of 13,219 health facilities out of 19,792 facilities have submitted their self-assessment of vaccination readiness through P-Care and were considered ready. 130. Vaccine requirements are likely to vary. Potential vaccines need to be transported and stored in cold-storage facilities with different temperature requirements. Due to logistical constraints, only vaccines with feasible, low-cost distribution and logistics and longer shelf-life are likely to be procured. Vaccines requiring ultra-low temperature for their transportation and storage, such as those from Pfizer and Moderna, if procured, will likely be distributed in urban centers where there are limited logistical constraints. Furthermore, Pfizer vaccines are known to have shorter shelf life after they are taken out of their ultra thermal shippers46, making it important to distribute the vaccines as fast as possible. 131. At the delivery point, vaccines should be administered by trained healthcare workers. Considering the disparity of healthcare capacity across regions, areas with low ratios of healthcare workers per- population in remote regions, particularly in Eastern Indonesia, potential constraints may be anticipated with the required outreach and administration of the vaccines in these regions. MOH is rolling out a series of workshops targeted to healthworkers administering COVID-19 vaccination. A total of 18,008 participants across 34 provinces have been trained as of 9 th January 2021. The majority of whom are from urban centers where the pandemic hit the worst. Such training is currently on-going, with potential adjustments to accomodate future developments of COVID-19 vaccines. 132. A national COVID-19 vaccination program is a massive undertaking that requires the deployment of a high number of healthcare workers. At the same time with the rate of infection still surging, there is a considerable strain on the healthcare system to respond to increasing demand for hospitalization. MOH needs to ensure that adequate resources and personnel are secured to avoid any major disruption to other lines of healthcare services including COVID-19 Tracking, Testing and Treatment (3Ts). Reducing the rate of transmission and hospitalization through other existing measures (physical distancing and travel restrictions) may be needed prior and during vaccination roll-out. D.3.7 Feedback and Grievance Mechanism 133. Multiple channels have been utilized to accommodate grievances and inquiries related to COVID- 19 emergency response, notably HALO Kemkes Contact Center and 119 Hotline Service. These channels are being operated by different departments within MOH, with HALO Kemkes (calls, text, email, letter, and social media), operated by the Communication Bureau and 119 Hotline operated by the Directorate of Referral Services. The same channels are anticipated to be retained for the COVID-19 vaccination roll out. However going forward, it is necessary to harmonize the different roles of these two channels and to strengthen their complementary and their operational interaction. Furthermore, HALO Kemkes and 119 Hotline are not the only existing FGRM channels managed by MOH. Other platforms such as LAPOR (managed by KSP) and through Hotline Pengaduan 46Pfizer-BioTech, “COVID-19 Vaccine U.S. Distribution Fact Sheet | Pfizer,� November 2020, https://www.pfizer.com/news/hot- topics/covid_19_vaccine_u_s_distribution_fact_sheet. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 44 Ombudsman as well as a range of local hotline services can be mobilised to receive complaints from citizens. It is still unclear how these existing channels work and interact with each other. Strengthening the coordination and clarifying the operational interaction protocols between these channels will be crucial to ensure that any complaints received by any of these channels, national or local, are responded to adequately and quickly. A smooth interaction between various feedback and grievance channels will also ensure that complaints as well as subsequent resolution and resettlement are well documented and evaluated. 134. From the compiled data of complaints handling 1 January 2020 -30 September 2020, the recorded complaints for MOH’s Inspectorate General (Inspektorat Jenderal) overwhelmingly came from emails (none from calls or text and only one from social media). Most of the complaints were deemed to be outside the purview of MOH’s Inspectorate General and there was no further documentation of the process and the outcome of the complaint redress once it was dispatched to relevant organizations. Based on HALO Kemkes’s SOP, citizens are also required to input their personal data in the system before their complaints are being handled. This requirement may provide further barriers for citizens to provide feedback and convey their grievance. There is a need to strengthen the process of redress and resettlement of grievances related to COVID-19 between different channels within and beyond MOH, especially on aspects related to back-end processing of grievance, redress and settlement. 135. On January 12, 2021 BPOM has issued EUA for SinoVac vaccines, followed by Astra Zeneca in March 2021, allowing for the commencement of the first phase of the vaccination campaign specifically for healthcare workers. It is highly likely that any COVID-19 vaccines will be rolled out using Emergency Use Authorization (as per Presidential Regulation on COVID-19 Vaccination). Therefore, their long-term efficacy and side-effects are not fully known. Some adverse effects may be exceedingly rare and are undetected during clinical trials that involve tens of thousands of individuals. It is crucial then to set up a system to closely monitor vaccinated individuals. Indonesia has a mechanism in place to detect any adverse events of basic immunization programs. It is envisioned that the COVID-19 vaccination will utilize the same mechanism. However, given that COVID-19 vaccination is a massive new undertaking with the goal to inoculate most adult population to reach herd immunity, it is important to strengthen the capacity of the existing system to receive and respond to any complaints related to side and adverse effects. Existing channels of public communication (i.e., HALO Kemkes, 119 hotline service, Ombudsman and LAPOR) must also be widely made accessible to accommodate reporting of vaccination adverse events and a clear protocol to refer individual complaints immediately. Going forward, the assessment also recommends deployment of random checks and follow-up across different population groups (aggregated by sex, age, socio-economic status and other risks factors) following vaccination to assess their conditions, identify any side-events (from light to severe), and provide treatments whenever necessary. Comprehensive and accurate documentation of these cases will be essential for future improvement of available vaccines, their distribution plans and the overall Program implementation. D.3.8 Data and Privacy 136. The development and use of vaccination registry should only be used for vaccination purposes and individual privacy should be protected. Individual identifying data should only be accessible to officials and workers associated with the vaccination and should not be shared with other parties. On the need for data and privacy protection, MOH’s Pusdatin is governed by ISO 27001 on Information Security Management System. However, system capacities for data and privacy protection under a national scale COVID-19 vaccination remain to be seen. While some features, such as smart checking to only grant access to only authorized individuals and integrity pacts, are Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 45 included in the overall system, MOH’s ability to monitor may be limited since data entry points are located at the sub-national level. 137. Under the PforR, the extent of personal data being shared and collected throughout the vaccination process should adhere to the minimum standard and purposive limitation of individual data privacy in line with the General Data Protection and Regulation (GDPR), which is the main reference for the Personal Data Protection Bill. No information irrelevant to vaccination programs could be shared and/or collected. The development and use of the population database registry should only be used for vaccination purposes and individual privacy should be protected. Individual identifying data should only be accessible to officials and workers associated with the implementation of vaccination and should not be shared with other parties without consent from authorities. 138. Based on public consultations, several community-based organizations raised the concerns of privacy related to individual status as people living with HIV (PLHIV). The vaccination procedures require PLHIV to disclose their status and to present their latest CD4 count (to be eligible the CD4 count should not be lower than the prescribed threshold). However, PLHIV may potentially face undesired implications and risks when disclosing their status. Fear of stigma, discrimination, and potential socio-economic repercussions are some of the deterrence factors, which potentially discourage disclosure of health information and may present health risks due undisclosed co- morbidities and lack of access to proper health screening, such as CD4 count. It is important to ensure that all involved personnel will uphold and guarantee the confidentiality of such disclosure. Vaccination should also be provided in a safe space and manner where PLHIV can disclose their status without the fear of being overheard. D.3.9 Roles of Military and Security Forces 139. Under the national COVID-19 vaccination program, the police force has been involved to provide additional capacities to provide security services for vaccine distribution logistics at the provincial level (Minister of Health letter no. SR.02.06/II/346/2021). MOH has also requested additional capacities of medical staff (i.e., doctors and vaccinators) at health facilities owned by the National Police Force designated as vaccine administration points (MOH Secretary General Letter no. SR.02.06/C.II/558/2021). Military involvement may also be engaged as indicated in the draft manual for COVID-19 vaccination. The GoI does not envisage involvement of non-medical personnel from the military and police force for the purpose of COVID-19 vaccine delivery. Under this circumstance, while risks related to Sexual Exploitation and Abuse/Sexual Harassement (SEA/SH) as a result of involvement of military and security forces are expected to be low since passive surveillance at vaccination posts is available, relevant mitigation measures with regards to public communication, awareness of respectful environment for the purpose of COVID-19 vaccination and access to FGRMs are warranted under the Program. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 46 E ENVIRONMENTAL AND SOCIAL RECOMMENDATIONS AND ACTIONS 140. The recommended measures (on the following page) has been shared with MOH, with some pending actions currently being negotiated with MOH. The proposed action plans correspond to each of the area of concern under the ESSA addendum. The draft ESSA addendum report has been disclosed with Executive Summary and Environmental and Social Action Plans circulated to stakeholders consulted in Bahasa Indonesia. Further consultations are being organized with relevant stakeholders prior to the closing of the appraisal. The ESSA addendum, along with its proposed action plans will be finalized and re-disclosed following negotiations and prior to the Board approval. 141. Relevant environmental and social action plans under the parent PforR remain valid, with enhancement measures recommended as part of the ESSA addendum. The World Bank will undertake periodic monitoring of the progress of the proposed environmental and social action plans. Such monitoring will be part of joint-regular implementation support missions between MOH and the World Bank and DLI verification processes by independent verifiers (i.e. Finance and Development Monitoring Agency or hereafter BPKP). Technical support for the implementation of the proposed action plans will be provided on a need basis at the request of MOH. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 47 Table 6: Environmental and Social Action Plans No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures Population targeting, social inclusion and equity 1. Building on the MOH’s Directorate of Sub-set No N.A Prior to Phase 4 An MOH’s circular on Technical Guideline as Surveillance and of DLI# (scale up to the bottom-up registration issued through the Decree of Health 13 general issued and disseminated. Directorate General of Quarantine (Dit. population) The relevant protocol to Disease Control and SKK), be incorporated in the Prevention of MOH Immunization COVID-19 Technical (HK.02.02/4/423/2021), Sub-division; Guideline once available. define and implement a Center for Health protocol for bottom-up Data and enrolment/registration to Information complement the top-down (Pusdatin) One Data for COVID-19 Vaccination (Sistem Satu Data COVID-19 Vaksinasi) from the lowest level of government, including a pathway for individuals to report their eligibility in case they are excluded despite their eligibility. MOH shall initiate a dialogue with the Ministry of Home Affairs (MoHA) for the development of an inclusive vaccine registration mechanism for individuals without NIK. MOH shall ensure access to and allocation of Program benefits in a fair, equitable and inclusive manner, taking Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 48 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures into account the needs of individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable in line with WHO SAGE Values Framework for the Allocation and Prioritization of COVID-19 Vaccination. 2. Develop and implement MOH’s Center of Sub-set No N.A By July 31st 2021 An HR strategy to ensure throughout the Program, a Health Human of availability of HR for human resource strategy in Resource DLI#12 COVID-19 vaccination line with WHO’s Interim Planning and Use .1 and non-COVID-19 Guideline on Health (Pusrengun), essential health services Workforce Policy and Center of in lagging and Management in the Context Education for underserved regions of the COVID-19 Pandemic Health Human Response to ensure the Resource availability of human (Pusdik), Council resource for COVID-19 of Health Human vaccination and non-COVID- Resource (KTKI) 19 essential health services in lagging and underserved regions. Public health communication strategy and stakeholder engagement 3. Enhance the existing MOH’s Directorate of Sub-set No N.A. (to be Enhancement of Improved COVID-19 Communication Strategy in Health Promotion of DLI re-assessed MOH’s COVID- Communication Strategy line with WHO Risk (Promkes), #9.1 during 19 addressing specific Communication and Communication imple- Communication elements in the action Community Engagement Bureau mentation) Strategy prior to plan. (RCCE) Action Plan (Rokomyanmas) Phase 4 (scale up Guidance COVID-19 Directorate of to the general Preparedness and Response, Surveillance and population) and is Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 49 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures and WHO Vaccine Safety Health implemented Events: Managing the Quarantine (Dit. throughout the Communications Response in SKK), Program view of promoting social Immunization implementation inclusion and social Sub-division, acceptability of the GoI’s vaccination program through: - Develop inclusive messages and outreach strategy for population groups that are facing barriers to access information marginalized population groups; - Disseminate information regarding the vaccination plans including prioritization, bottom-up enrolment/registration process, Feedback Grievance Redress Mechanism; Create demand and use persuasive approaches, by emphasizing benefits of vaccination and addressing misinformation - Be inclusive and sustained stakeholder engagement - Monitor vaccine acceptance/hesitancy, misinformation, and implementation of non- Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 50 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures pharmaceutical interventions. 4 Develop, and implement Directorate of Sub-set No N.A Prior to Phase 4 Information on COVID- throughout the Program, Surveillance and of DLI (scale up to the 19 vaccination made channels of information such Health #9 general available to the public in as a public dashboard where Quarantine (Dit. population) an accessible and public can monitor the SKK), inclusive manner subnational allocation of Immunization vaccines and the number of Sub-division vaccinated persons with information on how to report mismanagement Vaccine safety and consent 5. On this issue, the previously proposed PAP action stands deleted and a covenant has been incorporated in the draft legal agreement.“the Borrower shall carry out the Program in conformity with appropriate administrative, technical, financial, economic, environmental and social, and public health standards and practices, including best practices in public vaccination.� 6. Enhancement of COVID-19 Directorate of DLI Yes Bi-annual As part of the Implementation of pharmacovigillance measures Surveillance and #14 progress PforR pharmacovigilance, including: Health reports implementation including through a • Bottom-up surveillance Quarantine (Dit. throughout bottom-up/ for Adverse Events SKK), imple- community based process following Immunization Immunization mentation is reported through (AEFI) and FGRM; Sub-division administrative data/ • Relevant capacity reports. building for vaccine administrators on relevant communication and handling of AEFIs; • Procedures in place for AEFI response, including medical treatments and compensations Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 51 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures Note: vaccine safety through end-to-end supply chain and logistic management has been addressed as part of DLI #11 Handling of grievances 7. Enhance the existing Directorate of Sub-set Yes throughout As part of PforR A FGRM enhancement Feedback and Grievance Referral Services of DLI imple- Implementation action plan for COVID- Redress Mechanism (FGRM) (PKR), #9.1 mentation (existing FGRM 19 vaccination prepared through MOH’s Hotline for Directorate of channels are in and implemented jointly COVID-19 (119) and HALO Surveillance and place) with relevant departments KEMKES. Enhancement Health within MOH and other measures include Quarantine (Dit. relevant stakeholders incorporating a bottom-up SKK), pharmacovigilance reporting, Directorate of synchronization with Health Promotion multiple FGRM channels and Community within and outside MOH to Empowerment enable systematic (Promkes), monitoring, tracking, follow- Communication up and settlement. Bureau (Rokomyanmas) The FGRM will be publicized, maintained and operated to receive and facilitate resolution of concerns and grievances in relation to the Program, promptly and effectively, in a transparent manner that is culturally appropriate and readily accessible to all Program-affected parties, at no cost and without retribution, including Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 52 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures concerns and grievances filed anonymously. Individual data privacy particularly with regards to individual targeting and tracing 8. Develop a guideline to Center for Health N.A. No N.A A guideline for A guideline for privacy protect data privacy and Data and (buildin privacy and data and data confidentiality confidentiality (i.e., smart Information g on an confidentiality measures in line with checking, non-disclosure (Pusdatin) earlier measures within good practices in agreement, integrity pacts for action Pusdatin is a personal data data administrators) in line plan) condition for management within with good practices in effectiveness and Pusdatin in place and personal data management. implemented implemented. throughout the Program Pollution Prevention and Management 9. Conduct/update rapid Directorate N.A. Yes Throughout By June 30th and Rapid assessment for assessment on current Environmental Program monitored hospitals and primary capacity/practice in hospitals Health; implementat throughout healthcare facilities and primary healthcare ion Program participating in the facilities participating in the implementation vaccines delivery for the vaccines delivery to manage Program has been medical waste and the conducted and expected volume of waste continuously monitored generated during the throughout Program vaccination campaign. implementation 10. Update and implement Directorate Subset No N.A. Protocol is Protocol to ensure safe protocol to ensure that the Environmental of DLI updated in the management of vaccines acquisition, storage, Health #11.2 technical purchase, storage, transportation and handling guidelines 30 transportation and of vaccines (including, ultra- Directorate of days after handling, as well as waste cold chain management) is Surveillance and effectiveness and from vaccination conducted in a safe manner, Health implemented activities are updated and and adequately manage and Quarantine (Dit. throughout the implemented dispose of health care wastes SKK), Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 53 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures from vaccination activities in Immunization Program line with WHO guideline on Sub-division implementation safe management of wastes from health-care activities DG of Pharmacy and WHO technical brief on and Medical water, sanitation, hygiene Equipment and waste management for COVID-19 11. Provide training to healthcare Directorate N.A. Yes Based on Ongoing Number of training workers, local environment Environmental needs sessions delivered agency, local health agency Health on the management of COVID-19 vaccine wastes in line with WHO guidance on Safe Management of Wastes from Healthcare Activities and WHO technical brief on water, sanitation, hygiene and waste management for COVID-19. Occupational Health and Safety 12. In conjuction with PAP 2, The Center for N.A. No N.A Assessment as Additional PPEs needed assess and procure additional Health Crisis of condition for for COVID-19 PPEs needed for COVID-19 MOH effectiveness, and vaccination has been vaccination program in line procurement assessed, procured, and with WHO guideline on throughout the distributed to designated Rational Use of Personal Program vaccine facilities Protective Equipment for implementation Coronavirus Disease 2019 (COVID-19). 13. Update and implement Directorate of No No N.A Protocol is Protocol is available and protocols on occupational Surveillance and updated in up to date and widely health and safety measures Health technical disseminated during vaccination activities Quarantine (Dit. guidelines 30 (including infection SKK), days after Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 54 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures prevention and control and Immunization effectiveness and personal protective Sub-division implemented equipment) and labor throughout management (including Program working conditions) in line implementation with WHO Infection prevention and control (IPC) principles and procedures for COVID-19 vaccination activities. 14. Provide training to healthcare Directorate of Subset Yes Based on Ongoing Number of training workers who are involved in Surveillance and of DLI needs sessions delivered vaccination program, Health # 12.2 through modalities including on safe Quarantine (Dit. suitable for the types of management of vaccines per SKK), skills being trained the guideline under PAP 10; Immunization Infection and Prevention Sub-division Control (IPC) measures during vaccination and PPE usage in line with WHO Infection prevention and control (IPC) principles and procedures for COVID-19 vaccination activities. Community Health and Safety 15. Monitor application IPC Directorate of No Yes Bi-annual Throughout Monitoring and training measures in COVID-19 Surveillance and reporting Program delivery reports vaccine administering Health implementation facilities and adherence to Quarantine (Dit. handling of vaccine waste SKK), management, including Immunization requisite training to vaccine Sub-division administering facilities in line with the following WHO guidelines: Safe Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 55 No. Action Responsibility DLI Recurrent Frequency Due Date Completion Measures Management of Wastes from Healthcare Activities, Technical Brief on Water, Sanitation, Hygiene and Waste Management for COVID-19, and Infection Prevention and Control (IPC) Principles and Procedures for COVID-19 Vaccination Activities. Respectful Workplace Environment 16. Issue a circular on ensuring Directorate of No No Bi-annual Prior to Phase 4 A circular on ensuring respectful environment for Surveillance and (scale up to the respectful environment the purpose of COVID-19 Health general along with relevant media vaccination to the sub- Quarantine (Dit. population) for public messaging national governments along SKK), available and with culturally appropriate Immunization disseminated. media for public messaging Sub-division, (i.e., pamphlet, poster, etc.) Directorate of that contains FGRM Health Promotion channels accessible to the and Community public. Empowerment, Communication Bureau (Rokomyanmas) Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 56 F ENVIRONMENTAL AND SOCIAL RISK RATING 142. Similar to the parent PforR, the environmental and social risk under the AF is deemed to be substantial. There is a likelihood the Program would lead to some E&S consequences, but the risks are predictable and can be managed through risk management measures. The current strained capacity in responding to the pandemic may contribute to the possibility of the Program may not achieve its environmental and social operational objectives or sustain the desired environmental and social outcomes. 143. Risk areas of concern considered under the AF are aligned with the Vaccine Introduction Readiness Assessment Tool (VIRAT)/Vaccine Readiness Assessment Framework (VRAF) as recommended by the World Bank, WHO and UNICEF. These include a) population targeting, social inclusion and equity; b) public health communication and stakeholder engagement; c) individual rights to vaccination and consent, particularly amongst population groups who are sceptical and/or refuse vaccination; d) handling of grievances, including pharmacovigilance measures to monitor adverse events; e) individual data privacy; e) environmental pollution and community health and safety issue related to the handling, transportation and disposal of COVID-19 vaccine wastes (i.e. syringes, vials, PPEs, etc.); f) vaccine safety related to end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management – including rigorous cold chain control; g) Occupational Health and Safety (OHS). Proposed environmental and social action plans under the AF are aimed to enhance existing systems and measures to correspond to these areas of concern. 144. GoI’s vaccine prioritization is generally aligned with the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and Indonesian Technical Advisory Group on Immunization (ITAGI). COVID-19 vaccination seeks to focus on reduction of direct morbidity and mortality and maintenance of most critical services, while considering reciprocity towards groups that have been placed at disproportionate risks to mitigate consequences of this pandemic (i.e. frontline health workers). Adults of 18 – 59 age bracket will receive priority for vaccination with the view of availability of vaccines as well as safety. Further, by vaccinating more socially mobile and economically active populations, the GoI anticipates reaching herd immunity more quickly. There are about 181.5 million people to be vaccinated (or 67 percent of the population), requiring 426 million doses of vaccines with a double-dose regimen and 15 percent wastage. 145. There are risks of social refusal for vaccinations and some sub-national governments are contemplating to introduce sanctions for people who refuse to be vaccinated. However, whether and how sanctions will be enforceable is unclear and is a matter of debate since there are no guidelines and/or operational manuals to enact relevant provisions on sanctions in the regulation. Under this PforR, public health communication for COVID-19 vaccination should emphasize persuasion. A legal covenant has been agreed to ensure that the GOI carries out the Program in conformity with, inter alia, best practices in public vaccination. Provisions for medical exemptions are also already included in the technical guidelines of the MOH, which also forms part of the screening by health workers prior to each vaccination. It will be important to monitor the implementation of the vaccination program to ensure good practices are being adhered to. 146. Disparity between hazardous medical waste volume and the processing capacity remains the biggest challenge in managing COVID-19 related wastes in Indonesia, especially in the regions outside Java. More than half of licensed medical waste processing facilities and transporters are located in the island. It is expected that additional medical waste generated from COVID-19 vaccination activities may add more burden to the now-strained medical waste management system. MOH and MOEF has led various efforts in improving medical waste management in the country, these include distributing and constructing additional medical waste processing equipment, developing and disseminating COVID-19 waste management guidelines, and conducting training and webinar for Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 57 healthcare workers and local environment/health agencies. Additional guidance on management of waste during vaccination activities is already included in the recently published vaccination technical guideline. Continuous interagency cooperation in addressing concerns related to medical waste management and its supervision remains critical in ensuring the proper implementation of relevant regulations and guidelines. 147. There is a risk COVID-19 exposure to healthcare workers during vaccination activities. Specific measures pertaining to OHS requirements during vaccine administration are included in the MOH’s technical guideline for COVID-19 vaccination. The measures include a) priority vaccination for those administering vaccination, including supporting personnel; b) application of health and basic hygiene protocols, and use of PPEs, c) social distancing requirements, d) fatigue management by capping daily quotas. Additional PPE supplies for healthcare workers and other personnel involved in the vaccination program is also needed. Logistical planning for vaccination, which consider the needs to assess and procure PPEs, is also prescribed in MOH’s technical guideline. A system to monitor the distribution of vaccines and other logistics, including PPEs, have been developed. The implementation of this monitoring system is critical to ensuring healthcare workers are properly equipped with PPE so as to minimize exposure risk. Prioritizing healthcare workers to receive the vaccines is expected to provide infection protection to these workers as frontliners. 148. While it is acknowledged that under the pandemic situation the government will need to thread and balance carefully the human wellbeing objective (of reducing COVID 19-related deaths and morbidity) and the objective of economic recovery especially in making decisions about prioritized groups, there are concerns that the government may focus on economic recovery more than public health goal. There may be trade-off but there are also ways to reconcile the two objectives. Prioritizing healthcare workers, essential sectors, and vulnerable populations may help to reduce the number of deaths and severe illnesses, to ease the strain on the health system, and at the same time contribute to economic recovery. 149. People in remote areas, including vulnerable groups such as Indigenous Peoples and marginalized groups such as people with disabilities, LGBTQI, religious minorities may face constraints in accessing COVID-19 vaccines despite their willingness to be vaccinated. The assessment acknowledges that access equity remains low, with disparities in geographical access, health worker distribution, and quality of services, particularly in Eastern Indonesia. People who are not part of any government’s registries or whose domicile do not match their administrative records may be excluded. This population may include, but not limited to, circular or seasonal migrants, homeless people and street children, transgender population, and isolated populations. As the transmission is disproportionately high in urban areas, certain urban populations might also be inadvertedly excluded from targeting and identification due to mismatch between their actual residential address and their administrative records. They include people living in informal settlements, newly arrived migrants who have not updated their administrative record, as well as seasonal and transient migrants (including migrant students). Measures to address exclusion errors are therefore critical understanding that there are likely loop holes in the existing One Data Information System for COVID-19 Vaccination. Such measures will need to be responsive and agile to inform vaccination planning due to limited availability of vaccines in the near and medium-term. 150. Gender inequalities may likely exacerbate access to healthcare. These may stem from access issues (i.e. access to information, services, and trade-offs with domestic responsibilities) as well as socio- cultural barriers where men may get prioritization. Further, since pregnant women are not eligible for vaccination, it is not clear with regards to their access following labor and/or whether there will be prioritization for women who expect pregnancy prior to vaccination. Understanding that COVID-19 vaccination may take up precious health resources, which are already strained particularly in lagging regions, there are risks that such a program may disrupt the regular maternal Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 58 health services, including ante- and post-natal care. Women-friendly and safe spaces for vaccine delivery are also an important element to ensure well-being of women during vaccination. 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World Health Organization (2020). WHO SAGE Roadmap for Prioritizing Uses Of COVID-19 Vaccines in The Context Of Limited Supply, 13 November 2020. Geneva: World Health Organization. World Health Organization (2020) WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination, 14 September 2020. Geneva: World Health Organization. World Health Organization (23 September 2020). Indonesia COVID-19 Situation Report – 26, online, accessed on 17 November 2020. Jakarta: World Health Organization. https://www.who.int/docs/default- source/searo/indonesia/covid19/external-situation-report-26-23september2020.pdf?sfvrsn=3b0eba36_2 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 62 ANNEX 1: Summary of DLIs for the Additional Financing Disbursement Linked Disbursement Linked Results Baseline Target including Notes/Formula Indicators Updated Target (1) DLI #1: Specific DLR #1.2: The Implementation 0 The policy to Value: US$ 40 million additional measures to Guidelines for Health Professionals’ provide incentives Scalable/monthly payment: Unit support and compensate Support for COVID-19 response and death Price: $3,333,333 per Calendar health professionals for remain in place and the payment of compensation is month in 2021 that the added COVID-19 related benefits has been continued in 2021. continued for all Guidelines for Health workload and risk are calendar quarters Professionals’ Support remain in implemented in 2021. place and the payment of benefits has been continued. (3) DLI #3: Increased DLR #3.3: In each calendar quarter 0 More than 90% Value US$ 10 million (Unit capacity for patient of 2021, at least 90% of hospital for each quarter Price: isolation and medical care claim payments for treating COVID- $2,500,000 for every calendar 19 patients have been received by the quarter of 2021 that the Target is hospital within 10 business days after met. the receipt of the verification for such (Prior result for the first calendar claims by MOH. quarter of 2021) DLR # 3.4: Number of COVID-19 patients with moderate to severe Target: In each calendar quarter illnesses that receive hospitalization of 2021, at least 90% of hospital and have their claims paid for by the claim payments for treating MOH, on or after the date of 0 200,000 COVID-19 patients have been signature of this Agreement. received by the hospital within 10 business days after the receipt of the verification for such claims by MOH Value US$ 60 million. Scalable. Unit Price: $300 for each claim paid for COVID-19 patients receiving free hospital treatment, up to the Target. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 63 (4) DLI #4: Health DLR #4.2: 2000 additional high care 0 in May 2020 2,000 new beds Scalable; Value: U$ 50 million facilities’ readiness for beds in existing medical facilities Current value is over and above the Unit Price: $25,000 per high care emergency response outside Jakarta are equipped to 2,355 current bed fully equipped pursuant to manage severe respiratory illnesses achievement. the National Protocol, up to pursuant to the National Protocol (of 2,000 new beds over and above which at least 50% are equipped with the Baseline. ventilators) Current value: 2,355 is the # of high care beds outside of Jakarta 2020 (7) DLI #7: Installed DLR 7.3 Borrower has tested 1 5 Provinces 20 Provinces Total value: US$ 45 million capacity of quality- person per 1000 population per week Scalable, Unit Price: assured COVID-19 (including polymerase chain reaction $3,000,000 per new Additional confirmatory tests per (PCR), rapid molecular and rapid Province where 1 person per day antigen tests) in the Additional 1000 population per week is Provinces. tested up to the Target. Target: 15 Additional Provinces Note: The five provinces as the baseline; DKI Jakarta, Daerah Istimewa (DI) Yogyakarta, Kalimantan Timur, Kalimantan Selatan, Kalimantan Utara. DLR 7.4 The Borrower has 0 provinces 34 provinces Value US$ 51 million; Scalable; introduced Rapid Antigen Testing in Unit Price: $1,500,000 per all Provinces. Province that has completed the first 10,000 Rapid Antigen Testing up to the Target. DLR 7.5 The Borrower is 0 At least 300 Value US$ 15 million; Scalable: undertaking regular genomic samples for every Unit Price: $5,000,000 per surveillance for variants of the calendar semester calendar semester in which at COVID-19 virus. from January 2021 least 300 samples are tested for to June 2022. genomic variants of the COVID- 19 virus during the Target period. Target: 300 tests per calendar semester during January 2021 to June 2022 Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 64 (9) DLI # 9 DLR # 9.2 By no later than 0 COVID-19 Value: US$ 10 million. Communications strategy September 30, 2021, MOH has vaccine-related on COVID-19 based on updated the communication strategy update to the experience and lessons- for information on COVID-19 MOH learned vaccines, their rollout, eligibility, communication grievance redress as well as adverse strategy is event information. available (11) DLI # 11 Assess and DLR 11.1 By no later than July 31, 0 Cold chain action Value: US$ 10 million plan actions to address 2021, the Borrower has developed an plan is developed gaps in supply chain and action plan to address identified gaps and under logistics for maintaining in supply chain and logistics for implementation. the cold chain for storage maintaining the cold chain from and distribution of points of entry to points of service for COVID-19 vaccines vaccines. DLR 11.2 The Borrower has 0 a) Remote DLR #11.2 Value: US$ 45 deployed remote temperature temperature million. monitoring devices in vaccine storage monitoring is locations (not including Jakarta) and installed and DLR #11.2 (a) US$ 15 million. specifically: functioning at (i) Unit Price: $150,000 for each (a) remote temperature monitoring is the provincial and percentage point of Identified installed and functioning at the district level for Districts where remote Province and district level; temperature monitoring is all identified installed and functioning at the districts; Province and district level; (b) remote temperature monitoring is installed and functioning at the DLR #11.2(b): US$ 15 million. Puskesmas level; b) Remote temperature Unit Price: $150,000 for each monitoring is percentage point of Identified Districts where remote (c) end to end supply chain management installed and temperature monitoring is and logistics information system is functioning at the installed and functioning at the functional (at least for COVID-19 Puskesmas level Puskesmas up to the Target. vaccines) and regularly in use in 2000 in all identified Target: all Identified Districts Puskesmas up to March 31, 2022. districts. DLR #11.2(c): US$ 15 million. Unit Price: $7,500 per puskesmas where end-to-end supply chain Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 65 c) End-to-end management and logistics supply chain information system is functional management and (at least for COVID-19 vaccines) logistics and regularly in use, as of March information 31, 2022. system is functional (at least for COVID-19 vaccines) and regularly in use in up to 2,000 Puskesmas locations as of 31st March 2022. (12) DLI #12 Human DLR 12.1 By no later than July 31, 0 HR Mobilization Value: US$ 10 million. Resource Capacity 2021, the Borrower has developed a plan that preserves Building and Managing deployment/mobilization plan for essential services, unintended impact of ongoing COVID-19 response and is developed and COVID response on mass vaccination in a manner that implemented essential non-COVID preserves a share of staffing to health services maintain Essential Non-COVID Health and Nutrition Services. DLR 12.2 The Borrower has No MOH has received Value: US$ 20 million; Scalable. confirmed that appropriate capacity confirmation of Unit Price: $40,000 per district building/ training of human resources training that has confirmed that for COVID-19 vaccine delivery has completion for all appropriate capacity been carried out. districts building/training of human implementing resources for COVID-19 vaccine COVID-19 delivery has been carried out up to the Target. vaccination. Target: 500 districts Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 66 DLR 12.3 Essential Non-COVID 0 Targets for each Value: US$ 69 million Health and Nutrition Services are program will be Scalable; Unit Price: $3,000,000 utilized at more than 90% of pre- based on per calendar quarter for each COVID utilization, except for the (2019 performance) individual program achieving the Target in tuberculosis program, which is Programs & program each quarter between April 2021 utilized at 82% or higher of pre- Indicators** performance in and June 2022. COVID utilization Maternal 2019. Target: program is utilized at - K4 visits 88.5% more than 90% of pre-COVID (KOMDAT/ utilization, except for the Program tuberculosis program, which is reporting utilized at 82% or higher of pre- - Facility based Programs & COVID utilization: (a) in 3 delivery 88.6% Indicators quarters between April 2021 and (KOMDAT, Maternal June 2022 in the case of the Program) - K4 complete nutrition program; and (b) in each Nutrition visits quarter between April 2021 and Under 5s monthly - Facility based June 2022 for all other programs weighing 73.6% delivery (Program reporting) Nutrition TB Monthly Growth Case notification Monitoring of 67% (Program Children Under 5 reporting) TB Immunization Case Notification Pentavalent (3rd Immunization dose) 96.5 Pentavalent (3rd (Program reporting) dose) (13) DLI #13 Vaccine DLR 13.1. The Borrower has 0 Vaccine Value: US$ 25 million prioritization and developed fair and equitable criteria prioritization and distribution is based on for prioritization and distribution of distribution DLR 13.1 Criteria developed pre-determined, fair and COVID-19 vaccines across its criteria are and made publicly available: objective criteria. geographical areas through a developed, made US$5 million (prior result) consultative and transparent process. publicly available, and COVID-19 DLR 13.2 As of September 30, DLR 13.2 As of September 30, 2021, 2021, the COVID-19 vaccines vaccines the prioritization, deployment and distribution has conformed to the deployment and distribution of COVID-19 vaccines above criteria: US$10 million has conformed to the fair and distribution has DLR 13.3 As of December 31, 2021, the COVID-19 vaccines Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 67 equitable criteria referred to in DLR conformed to the distribution has conformed to the #13.1. criteria above criteria: US$ 10 million DLR 13.3 As of December 31, 2021, the prioritization, deployment and distribution of COVID-19 vaccines has conformed to the fair and equitable criteria referred to in DLR #13.1 (14) DLI #14 A DLR #14.1 The Borrower has 0 The Value: US$ 10 million pharmacovigilance developed and implemented a pharmacovigilance The system has the ability to system is in place to pharmacovigilance system to monitor system is developed track the exact batch of COVID- report adverse events in a any adverse events related to the and is providing 19 vaccine Pharmacovigilance timely manner COVID-19 vaccine(s). regular reports. system is developed DLR #14.2 As of September 30, Value: US$ 15 million 2021, the pharmacovigilance system As of September 30, 2021, the has been implemented and is 0 system is functioning and able to functioning in accordance with the track exact batch of COVID-19 ITAGI Guidance, to monitor any vaccines given to beneficiaries adverse events related to the Program COVID-19 vaccine. Value: US$ 15 million As of March, 31, 2022, the DLR# 14.3 As of March 31, 2022, system is functioning and able to the pharmacovigilance system has track exact batch of COVID-19 been implemented and is functioning vaccines given to beneficiaries in accordance with the ITAGI Guidance, to monitor any adverse events related to the COVID-19 vaccine. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 68 ANNEX 2: Intermediate and PDO indicators, by Results Area (new AF indicators in blue) Results Areas Intermediate Indicators PDO Indicators Improve hospital • Concrete measures to support and • Increased population and health system compensate health professionals for immunity to COVID-19, as readiness for added COVID-19-related workload and measured by number of COVID response risk are implemented persons who have received and vaccination, free vaccination with an and maintain • Number of beds temporarily converted eligible vaccine essential non- for patient isolation and/or low-intensity COVID health medical care • Reduced service readiness gap in treating serious services • Number of COVID-19 cases respiratory illness patients successfully treated, disaggregated by sex • Infection prevention and clinical management protocols developed and disseminated to all non-referral facilities • Maintaining essential non-COVID services – Number of completed fourth ANC services delivered in the previous quarter as a proportion to the corresponding quarter in 2019 • Number of functional locations with Strengthening • Strengthened laboratory public health remote temperature monitoring system. capacity laboratory, • surveillance, and Cumulative number of COVID-19 • Improved reporting and suspects tested by PCR or rapid surveillance system supply chain molecular testing, disaggregated by sex systems • A surveillance mechanism for community-based reporting of outbreaks and new illnesses among humans and animals is functional • Cumulative number of cases reported in the pharmacovigilance system Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 69 Results Areas Intermediate Indicators PDO Indicators Enabling • MOH supports the creation of a • Enhanced community communication and multisectoral coordination mechanism for engagement and coordination for COVID-19 response communication emergency response and • MOH counters COVID-19 related vaccine delivery misinformation and posts on its website • Cumulative number of cases MOH counters COVID-19 vaccine related misinformation and posts on its website • Cummulative number of website visitors to the COVID-19 communication portal set up by the Government of Indonesia Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 70 ANNEX 3: Implementation Progress of Environmental and Social Action Plans of the Parent’s PforR No. Action Responsibility DLI Re- Freq Due Status current Date Management of Medical Wastes 1. Nominate responsible Directorate of Yes No n.a. 31 May An appointment letter (SK) has been issued by staff from the MOH and Environmental (Subset 2020 MOH (Directorate of Environmental Health – no. MOEF to jointly advise Health of DLI HK.03.02/4/3429/2020 dated June 12, 2020), hospitals and laboratories 4) appointing a team in charge for oversight the in managing the management of medical wastes in healthcare increasing volume of facilities from MOH. MOH has also medical waste during the communicated such requirement to MOEF pandemic, including through an official letter requesting the through assignment of responsible staff (Letter No. KL.03.01/4/2854/2020 dated May 15, 2020). However, an equivalent SK is yet to be issued by MOEF on the premise that such oversight and coaching functions are part of MOEF’s regular duties and hence, a specific SK is not warranted. MOEF through regulation No. P.18/MENLHK- II/2015 outlines the mandate for each its Directorate Generals and Directorates. a. Conduct rapid Yes No n.a. 30 June Rapid assessments in a form of electronic survey assessment on current (subset 2020 to assess the current waste management practice capacity/practice in of DLI and capacity has been commissioned across the MOH’s vertically 4) hospitals and laboratories, with an uptake of 525 managed hospitals, respondents as of Oct 5,2020. Majority of the laboratories and field response were from hospitals. Information on the hospitals to manage proportion of respondents (e.g. referral hospitals, medical waste and the laboratories, etc.) has not yet provided. expected volume of waste generated Ad-hoc meetings with sub-national health during the pandemic agencies (province and district) were also undertaken to assess waste management capacities, including issues and challenges. Such meetings were expected to complement the Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 71 No. Action Responsibility DLI Re- Freq Due Status current Date survey findings. MOH will continue the survey to capture wider respondents and to coordinate with MOEF and sub-national health agencies. To be obtained: proportion of respondents by types of facility from current rapid assessment result (e.g. no of referral hospitals, other hospitals, laboratories, clinics, etc.) b. Advise hospitals and No Yes n.a. Ongoing Guideline on medical wastewater and solid waste laboratories on the management for healthcare facilities has been alternatives to manage issued on April 14, 2020 by the Directorate of their wastes (in house Environmental Health and posted in MOH and external services), website (here). Similar guideline but covering support approval of wider scope (including waste from all healthcare agreed options and facilities and community self-isolation) has also develop the necessary been issued by MOH through decree No. work instructions for HK.01.07/MENKES/537/2020. Both guidelines these alternatives. also provide alternative options for medical waste Based on agreed management in emergency and have been options for medical communicated to healthcare facilities in all waste management provinces through virtual training whrganized jointly with the MoH, jointly with MOEF, these training also served as support procurement platform for healthcare facilities in seeking advice for goods/ equipment on medical waste management (details in point c). where needed, facilitate dialogue MOH has also distributed four autoclaves to four with third parties referral hospitals in West Sumatera, Bali, (waste transporters, Yogyakarta and Central Java; and four cement kilns, landfills incinerators to Centre of Environmental Health for ash disposal, and and Disease Control Agency (BBTKL) in so on) Banjarbaru, Jakarta, Surabaya and Yogyakarta to strengthen medical waste management capacity in these regions. The distribution of autoclaves and incinerators were based on recommendations Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 72 No. Action Responsibility DLI Re- Freq Due Status current Date from the Directorate of Healthcare Services and DG Disease Prevention and Control. During the mission, it was noted that MOH received a complaint letter from local NGO on medical waste management in RSUD Djafar Harun, North Kolaka, Southeast Sulawesi Province dated August 24, 2020. The complaint highlighting the suboptimal operations of wastewater treatment plan and incinerators since 2017 and the possibility of corruption in procurement of these items. MOH has coordinated with subnational health and environmental agency in North Kolaka Regency and Southeast Sulawesi Province to investigate the issue and provide guidance on the management of the waste, through letter no KL.03.01/III/901/2020. To be obtained: investigation result and action plan following complaint investigation. c. Provide training to No Yes n.a. Ongoing MOH, collaborated with MOEF and WHO, held a hospitals and total of 17 e-training (webinars) on medical waste laboratories on the management practices during COVID-19, alternatives to manage covering audiences from sub-national health and COVID-19 wastes environment agencies (province and district) and (web-based training) healthcare facilities (referral and non-referral and providing hospitals, primary health care, laboratories) from guidance for third all 34 provinces on June 22 – July 16. Topics parties on medical covered include COVID-19 wastewater and solid waste management. management policies from MOH and MOEF, applicable regulations and guidelines, practical advice for implementation of these guidelines on site, as well as medical waste management guideline from WHO. A total of 15,360 audiences Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 73 No. Action Responsibility DLI Re- Freq Due Status current Date attended the training. These training sessions were recorded and available online (here). Occupational Health and Safety (OHS) 2. Training manuals and Directorate of No Yes n.a Ongoing Relevant technical instructions have been issued cascade training to Occupational and published (as of September 30, 2020). These hospital and laboratory Health of the include: workers for the proper MOH and - Use of PPE for the handling of COVID-19 handling of COVID-19 National patients (here) cases and specimens, Institute of - Protocol for Infection Prevention and Control including the proper usage Health (IPC) measures for healthcare settings (here). of PPE (web-based Research and This is the fifth revision to accommodate new training) Development knowledge related to COVID-19 based on of the MOH WHO recommendations. The above guidelines are publicly available and have been disseminated to health workers. 3. Priority testing for Directorate Yes Yes n.a. 30 June A guideline which prescribes priority testing for healthcare workers and General of (subset 2020 healthcare workers and facility staff has been facility staff responsible Health Service of DLI developed through Kepmenkes No. for direct handling of 1) HK.01.07/MENKES/1591/2020. COVID-19 at MOH vertical hospitals (i.e. cleaners, ambulance drivers, receptionists, etc.) Public Health and Safety 4. Additional capacity for DG of Health Yes No n.a. Ongoing COVID-19 Task Force, under leadership from the patient isolation and low- Service (DLI 3) National Disaster Management Authority intensity medical care by (Directorate of (BNPB), has established a COVID-19 emergency converting non-medical Health Facility hospital (RSDC) by converting an athlete dorm at establishments with the and/or Wisma Kemayoran for low-intensity medical needed equipment and Directorate of care. There are a total 2,391 rooms with 6,011 human resources Hospital beds (as of July 28, 2020). Services) Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 74 No. Action Responsibility DLI Re- Freq Due Status current Date To be obtained: MOH administrative records 5. A system for assessing The Center for Yes No n.a. 30 June As of September 30, 2020, 4,963,900 coveralls needs and monitoring Health Crisis of (sub- 2020 have been purchased, of which 4,448,304 have distribution of PPE to MOH for PPE; set of been distributed across the country. 4,795,892 of health facilities based on DLI 5) N95 masks have been purchased, of which needs across Indonesia* Directorate of 2,895,580 have been distributed (here). Surveillance This action plan also and Health MOH has used a forecasting tool developed by addresses equity issues in Quarantine for WHO, namely Essential Supplies Forecasting PPE distribution. Testing Kits; Tool (ESFT) to assess needs across provinces based on pandemic spread and growth. A logistic DG of dashboard is also up and running to track Pharmaceutical distribution and supplies. These systems are being Services for managed by the Public Health Emergency medical Operation Centre (PHEOC) of MOH. supplies Medical Consent and Civil Rights to Privacy 6. Measures to enhance the Directorate of No Yes n.a Ongoing Currently there are 10 personnel in charge for the existing public Feedback Referral MOH-operated FGRM systems (in three shifts), and Grievance Services including SMS and WhatsApp’s. The channels Mechanism (FGRM) for Bureau are accessible 24/7 and have been publicly COVID-19 response, such Communicatio disseminated through various media. Earlier as n Public FGRM management benefitted from additional https://covid19.kemkes.go Service, personnel from the Military and the Indonesia .id/ and hotline 119 ext. 9, Secretary National Police. Additional personnel, especially and ‘Halo Kemkes’ in General in preparation of COVID-19 vaccination is terms of their currently being assessed. accessibility, credibility and level of response Documents to be obtained: updated grievance records on COVID-19 management tracked with resolution status. 7. A protocol for Directorate for Yes No n.a. Ongoing MOH’s Centre of Data and Information surveillance incorporating Surveillance (sub- (Pusdatin) is leading the development of an data protection measures set of electronic platform integrating Tracking COVID- Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 75 No. Action Responsibility DLI Re- Freq Due Status current Date and consent is developed and Health DLI 6 19 application with Allrecords TC 19, with the and disseminated to health Quarantine; and 10) former serving as a dashboard to MOH facilities management and the latter serving as a data entry Center of platform. A protocol for data protection measures Health Data has been drafted, including a measure to encrypt and individual data points. The tracking application, Information including data storage and protection, is (Pusdatin) oversighted by the State Cyber and Code Agency (BSSN). To be obtained: completion and issuance of protocols and evidence of dissemination incorporating, as a minimum, the principles set forth in the Personal Data Management Protocol Social Stigma 8. A communication strategy Directorate of Yes Yes n.a. 31 May A public health communication strategy has been on public health Health (sub- 2020 prepared and launched by MOH. The Directorate messaging and Promotion set of of Health Promotion is in charge of the overall community outreach on Media: Bureau DLI 9) implementation of the strategy, together with the COVID-19 related facts, Communicatio Bureau of Communication of MOH. Cascaded in coordination with n and Public training has been implemented, targeting five media and civil society Service provinces (i.e. Jakarta, South Sumatera, South organizations and in line Kalimantan, Central Java and East Java) and with good practice select districts in these provinces, including guidelines such as primary healthcare facilities. Off-the-shelve https://www.who.int/docs/ media, such as flyers, pocketbooks, short-videos, default- have also been prepared and can be used by sub- source/coronaviruse/covid national governments, including primary care 19-stigma-guide.pdf facilities in their efforts to implement COVID-19 public health campaign. As of to date, there are no reported plans for the expansion of the cascaded training/coaching and in the future, such training/coaching will be made at the request of sub-national governments and/or health facilities. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 76 No. Action Responsibility DLI Re- Freq Due Status current Date Public risk communication has regularly used public media, including websites, social media, radios to make information related to COVID-19 and its risks publicly available. Relevant contents have been endorsed by technical units and dissemination has been made in coordination with other sectoral agencies, including the Ministry of Communication and Information (KOMINFO). For both on-going initiatives, evaluation of their efficacy and coverage is yet to be conducted. With planned COVID-19 vaccination, current public communication efforts will likely need to be overhauled. To be obtained: an assessment of MOH’s public communication strategy implementation Patients’ security and safety 9. Strengthen the existing Directorate No Yes Mont Ongoing As part of hospital accreditation, each health system to monitor General of hly facility is required to establish a Patient Safety patients’ security and Health Service Committee (Komite Keselamatan Pasien) that safety during isolation & (Directorate of will coordinate with the National Patient Safety treatment at COVID19 Health Facility Committee (Komite Nasional Keselamatan referral hospitals, and/or Pasien) under the oversight of the Directorate of including on aspects Directorate of Quality and Health Facility Accreditation. related to Sexual, Hospital Reporting to the national committee is voluntary Exploitation & Services) in nature. Complaints and/or cases are Abuse/Violence against categorized along generic classifications of Children (SEA/VAC) incidents in line with the Ministerial Regulation of MOH no. 11/2017 and hence, it is difficult to generate specific incident classifications, including SEA/VAC. The above system is expected to be complemented by the FGRM system operated by MOH to enable public access to file cases related to patients’ security and Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 77 No. Action Responsibility DLI Re- Freq Due Status current Date safety, which is expected to be enhanced going forward. To be obtained: cases reported to the national committee and whether there is a spike in the time of COVID-19. Evidence of an operating system to monitor and track risks related to patients’ wellbeing, including their security and safety during isolation and treatments at COVID-19 referral hospitals Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 78 ANNEX 4: Core Principles and Planning Elements of PforR No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program Core principle 1: Program E&S management systems are designed to (a) promote E&S sustainability in the Program design; (b) avoid, minimize, or mitigate adverse impacts; and (c) promote informed decision-making relating to a Program’s E&S effects. 1 The PforR system operate within an Relevant Relevant laws and regulations pertaining A national COVID-19 vaccination adequate legal and regulatory E&S impact assessments, management of program represents a massive framework to guide E&S impact medical waste, occupational health and undertaking with an unprecedented assessments, mitigation, management safety, community health and safety, scale in the country. The scale and and monitoring at the PforR Program individual rights to vaccination including speed that it requires to reach herd level. consent, grievance management, access and immunity will likely put a strain in the inclusion are available in the country. existing system for the national immunization program. At the same A comprehensive assessment for relevant time with the rate of infection still laws and regulations was conducted during surging, there is a considerable strain the preparation of Primary Health Care on the exisiting healthcare system to Reform PRogram - I-SPHERE (P164277), cope with the impacts of the pandemic Indonesia Emergency Response to COVID- and respond to increasing demand for 19 Program (P173843) as well as the AF. hospitalization. Logistical distribution, The assessment confirmed no significant with different temperature gaps with regards to policies, laws, and requirements for cold-chains, will be regulations. Vaccine prioritization is is challenged by the lack of generally aligned with the WHO Strategic infrastructure particularly in rural Advisory Group of Experts on areas, with limited vaccine availability Immunization (SAGE) and Indonesian and types of vaccines that urban Technical Advisory Group on Immunization populations may have access to. (ITAGI). Further, considering regional disparity, areas with low ratios of In terms of consent, while patient rights are healthcare workers per-population protected by law, individual consent can be particularly in remote regions in waived under emergency situations in the Eastern Indonesia, may face interest of public safety. On the basis of significant constraints with regards to these laws, COVID-19 vaccination is outreach, safety monitoring, and mandatory in nature and penalties are Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 79 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program enforceable by law for those who refuse on overall administration of COVID-19 the ground of personal preferences. This vaccination. represents a gap in the governing framework for the GoI’s vaccination program against the VIRAT/VRAF. 2 The PforR system incorporate Relevant GoI’s COVID-19 vaccination is generally The massive scale of the vaccination recognized elements of good aligned with the VIRAT/VRAF as Program likely strains the existing practice in E&S assessment and recommended for use by the World Bank, capacity of the Program to apply management including: WHO, and UNICEF, with the exception of proper E&S management consistently i. Early screening of potential individual consent as indicated earlier. across regions. In regards to OHS, impacts. Relevant measures to promote OHS and particular concerns are raised on ii. Consideration of strategic, nosocomial infections during vaccination access for healthcare workers to technical, and site alternatives has been included in the MOH’s technical Personal Protective Equipment (PPE). (including the “no action� guideline on vaccination services. A system to monitor the distribution alternative). has been established, and its iii. Explicit assessment of potential Guideline to manage medical wastes from implementation is critical to ensure induced, cumulative, and vaccination activities is also available in the adequeate PPE supplies are available transboundary impacts. technical guidance, with alternative methods all personnel involved. MOH is iv. Identification of measures to to manage the waste for healthcare facilities assessing the overall logistical needs mitigate adverse E&S risks and with limited access to licensed disposal for vaccination, including impacts that cannot be facilities are provided. procurement and distribution of PPEs. otherwise avoided or minimized. With the availability of alternatives to v. Clear articulation of manage the medical, effective institutional responsibilities and supervision and enforcement from resources to support relevant agencies is critical in implementation of plans ensuring the proper management of vi. Responsiveness and the wastes. accountability through stakeholder consultation, timely dissemination of the PforR information, and responsive GRMs. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 80 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program Core principle 2: Program E&S management systems are designed to avoid, minimize, or mitigate adverse impacts on natural habitats and physical cultural resources resulting from the Program. Program activities that involve the significant conversion or degradation of critical natural habitats or critical physical cultural heritage are not eligible for PforR financing. 1. The PforR Program system identify, Not Not Relevant Not Relevant and screen for adverse effects on Relevant potentially important biodiversity and cultural resource areas and provide adequate measures to avoid, minimize, or mitigate adverse effects. 2. The PforR Program system support Not Not Relevant Not Relevant and promote the protection, Relevant conservation, maintenance, and rehabilitation of natural habitats. 3. The PforR Program system avoid Not Not Relevant Not Relevant significant conversion or degradation Relevant of critical natural habitats. If avoiding the significant conversion of natural habitats is not technically feasible, include measures to mitigate or offset the adverse impacts of the PforR Program activities and take into account potential adverse effects on physical cultural property and provide adequate measures to avoid, minimize, or mitigate such effects. Core principle 3: Program E&S management systems are designed to protect public and worker safety against the potential risks associated with (a) the construction and/or operation of facilities or other operational practices under the Program; (b) exposure to toxic chemicals, hazardous wastes, and otherwise dangerous materials under the Program; and (c) reconstruction or rehabilitation. 1. The PforR Program system promote Relevant Occupational health and safety issues are While the country has a regulatory adequate community, individual, and covered in the accreditation system for framework and guidelines on OHS worker health, safety, and security hospital and puskesmas, as well as relevant and IPC in place, the current strained through the safe design, construction, regulations: capacity in the healthcare system is operation, and maintenance of challenging its optimal Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 81 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program Program activities; or, in carrying out Government Regulation (PP) No. 50/2012 implementation. Particular concerns activities that may be dependent on on Health and Safety Management. are raised related to the limited PPE existing infrastructure, incorporate MOEF Regulation No 56/2015 Appedix availability and long working hours of safety measures, inspections, or VIII provides guidelines on health worker the healthcare workers. remedial works as appropriate. protection, health and safety; MOH Regulation 66/2016 on Occupational Prioritizing healthcare workers to The PforR Program system promote Health and Safety at Hospital. receive the vaccines and allocating measures to address child and forced maximum daily working hours, as labor. Occupational health and safety measures prescribed in the COVID-19 during COVID-19 response and vaccination technical guidance, are vaccinations has also been developed. expected to protect these front liners from risk of COVID-19 exposure. 2. The PforR Program system promote Relevant Government Regulations No.101/2014 on Althogh the provisions in key the use of recognized good practice Hazardous waste management casts the regulations are in accordance to GIIP, in the production, management, country’s main hazardous waste uneven distribution of waste storage, transport, and disposal of management framework, which built upon management facilities hindering the hazardous materials generated under “cradle to grave� principle with a rigid optimal implementation of relevant the PforR. manifest system to track the flow of waste regulations in the country. Most of from the generator to the disposal facility. licensed waste management facilities The requirements prescribed in key and transporters are located in Java regulations are harmonized with the GIIP, Islands, with some areas outside Java including the provisions on waste have limited access to licensed identification, reduction, segregation, disposal facilities. storage, transport, disposal and occupational health and safety for waste handler – with Additional wastes generated from all activities to managing medical COVID-19 response and vaccination (hazardous) waste, including to store, program may add more burden to the transport, treat or dispose, require valid strained system. Alternative permit/license from relevant agencies. approaches to manage the waste should there is no licensed treatement facilities available are provided by MOEF Regulation No. 56/2015 on MOH and MOEF. Continuous Hazardous Waste Management from interagency cooperation in addressing healthcare facilities outlines the specific concerns related to medical waste Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 82 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program requirements on the management of management and its supervision hazardous medical wastes from all remains critical in ensuring the proper healthcare facilities, including from implementation of relevant regulations hospitals and primary healthcare facilities and guidelines. (puskesmas). MOEF circular letter No. SE.2/MENLHK/PSLB3/PLB.3/3/2020 on infectious (hazardous) and domestic waste management from COVID-19 response provides guidance and alternatives management of medical waste during the pandemic. 3. The PforR Program system promote Not Not Relevant Not Relevant the use of integrated pest Relevant management practices to manage or reduce the adverse impacts of pests or disease vectors 4. The PforR Program system provide Relevant MOH Regulation no. 46/2015 on Hazardous MOH and MOEF held various training for workers involved in the Waste Management from healthcare webinar and training on the production, procurement, storage, facilities make it mandatory for all management of COVID-19 related transport, use, and disposal of personnel involved in the management of medical waste over the course of the hazardous chemicals in accordance medical wastes to be trained. This implies pandemic. with the relevant international that personnel assigned to handle wastes guidelines and conventions from vaccination activites need to also be Specific training on the management trained. of medical wastes from vaccination activities is currently being conducted, with a further roll out covering more participants is expected. However, it is noted that the training materials for the first two session slightly differ with the guideline prescribed in Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 83 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program technical guidelines. Update on the guideline and training material is currently being proposed to synchronizing the information. 5. The PforR Program system include Relevant Law No 44/ 2009 on Hospital regulates that No significant gaps. However, since adequate measures to avoid, location of the hospital must comply with the national COVID-19 vaccination minimize, or mitigate community, environmental health and safety and spatial program is a massive undertaking both individual, and worker risks when the planning consideration. in terms of its scale and speed, PforR Program activities are located Ministry of Health Regulation No. 24/2016 implementation practices will likely in areas prone to natural hazards such on Technical Requirements for Healthcare vary, with weaker performance in as floods, hurricanes, earthquakes, or Buildings regulates that hospital buildings lagging regions with under-developed other severe weather or affected by must be free from natural hazards such as health systems. climate events. hurricanes, floods, earthquake (faults), steep slope, tsunami, at river bank area (erosion potential) etc. Core Principle 4: Program E&S systems manage land acquisition and loss of access to natural resources in a way that avoids or minimizes displacement and assists affected people in improving, or at the minimum restoring, their livelihoods and living standards 1. The PforR Program system avoid or Not Not relevant Not relevant minimize land acquisition and related relevant adverse impacts. 2. The PforR Program system identify Not Not relevant Not relevant and address economic or social relevant impacts caused by land acquisition or loss of access to natural resources, including those affecting people who may lack full legal rights to resources they use or occupy. 3. The PforR Program system provide Not Not relevant Not relevant compensation sufficient to purchase relevant replacement assets of equivalent value and to meet any necessary transitional expenses, paid before taking land or restricting access. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 84 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program 4. The PforR Program system provide Not Not relevant Not relevant supplemental livelihood relevant improvement or restoration measures if taking of land causes loss of income-generating opportunity (e.g., loss of crop production or employment). 5. The PforR Program system restore or Not Not Relevant Not Relevant replace public infrastructure and Relevant community services that may be adversely affected by the Program; include measures in order for land acquisition and related activities to be planned and implemented with appropriate disclosure of information, consultation, and informed participation of those affected. Core principle 5: Program E&S systems give due consideration to the cultural appropriateness of, and equitable access to, Program benefits, giving special attention to the rights and interests of Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities, and to the needs or concerns of vulnerable groups 1. The PforR Program system undertake Relevant The national COVID-19 vaccination Due to the emergency nature of meaningful consultations if the program does not disaggregate population COVID-19 vaccination roll-out, Indigenous targeting based on indigeneity status. Since community consultations, including Peoples/Sub-Saharan African consent may be waived, the provisions of exercise of consent, which may likely Historically Underserved Traditional consultations, including the exercise of be waived for public safety reasons, Local Communities are potentially individual rights to refuse vaccination for will be difficult to be implemented. affected (positively or negatively), to public safety reasons, are currently not The AF seeks to enhance MOH’s determine whether there is broad available in the current system. public communication, emphasizing community support for the PforR persuasion as well as tailored Program activities. messages to various different sub- population groups, including Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 85 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program vulnerable and marginalized population. 2. The PforR Program system ensure Not Not relevant Not relevant that Indigenous Peoples/Sub Saharan relevant African Historically Underserved Traditional Local Communities can participate in devising opportunities to benefit from exploitation of customary resources and indigenous knowledge, the latter (indigenous knowledge) to include the consent of Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities. 3. The PforR Program system give Relevant GoI’s COVID-19 vaccination is non- People in remote areas, including attention to groups vulnerable to discriminatory in terms of allocation and vulnerable groups such as Indigenous hardship or discrimination, including, targeting. The national allocation and Peoples and marginalized groups such as relevant, the poor, the disabled, prioritization is generally aligned with as people with disabilities, LGBTQI, women and children, the elderly, WHO SAGE. However, MOH’s COVID-19 religious minorities may face ethnic minorities or other technical guideline does not further specify constraints in accessing COVID-19 marginalized groups; and if vulnerable sub-groups, particularly those vaccines despite their willingness to necessary, take special measures to considered as vulnerable, disadvantaged, be vaccinated. The assessment promote equitable access to PforR underserved and/or impacted beyond health acknowledges that access equity Program benefits. and socio-economic dimensions and how to remains low, with disparities in identify these groups. geographical access, health worker distribution, and quality of services, particularly in Eastern Indonesia. People who are not part of any government’s registries or whose domicile do not match their administrative records may be excluded. This population may Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 86 No Key Attributes related to Core Relevance Provisions in System Practice Principles to Program include, but not limited to, circular or seasonal migrants, homeless people and street children, transgender population, and isolated populations. As the transmission is disproportionately high in urban areas, certain urban populations might also be inadvertedly excluded from targeting and identification due to mismatch between their actual residential address and their administrative records. They include people living in informal settlements, newly arrived migrants who have not updated their administrative record, as well as seasonal and transient migrants (including migrant students). Core principle 6: Program E&S systems avoid exacerbating social conflict, especially in fragile states, post-conflict areas, or areas subject to territorial disputes 1 The PforR Program system consider Not Not relevant Not relevant conflict risks, including distributional relevant equity and cultural sensitivities. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 87 ANNEX 5: Preliminary Environmental and Social Screening Indonesia COVID 19 Emergency Response Additional Financing (P175759, PE) PROGRAM FOR RESULTS Environmental and Social Initial Screening Introduction: The proposed Additional Financing (AF) will finance the scale-up Program activities and new activities to achieve Program Development Objectives (PDO) and enhance the impact of the parent Indonesia Emergency Response to COVID-19 Program (P173843). As the changes are aligned with the original PDO, the PDO would remain unchanged—to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Indonesia. This AF will play a critical role in enabling affordable and equitable access to vaccines to the GOI, as well as for nonvaccine immunization costs (e.g. personnel, transport, cold chain, surveillance, and quality assurance). Program Boundary: The Program for Results (PforR) is part of the World Bank’s support which in the short -term focuses on strengthening the Government of Indonesia’s (GOI) respond to the recent COVID-19 pandemic through increasing treatment and laboratory capacity, reporting and surveillance, and with this AF, immunity to COVID-19. In the medium-term, the Program also aims to reduce COVID-19 risk infection so as to reduce morbidity and mortality among program beneficiaries, while strengthening human capital and national system for public health preparedness for future resilience. The program boundary has increased to accommodate the purchase of eligible vaccines and other related commodities such as syringes, alcohol, immunization cards, personal protective equipment (PPE), institutional strengthening measures such as frameworks for the safe and effective deployment of COVID-19 vaccines, and system strengthening and service delivery efforts to ensure effective COVID vaccine deployment. The program boundaries will also be extended to not only covering COVID-19 referral hospitals and laboratories, but also primary care healthcare facilities ( puskesmas) as most of immunization services are held in this type of facility. The PforR closing date will be extended by one year to October 31, 2022. Purpose of initial screening: Within the scope of the AF, an additional assessment will be undertaken to also include environmental and social risks pertaining to COVID-19 vaccination activities supported by the PforR. Relevant aspects to be covered include: • Occupational Health and Safety (OHS) and community health and safety related to the overall administration of COVID-19 vaccination, including potential contacts and exposure with high risk population groups, perceptions of efficacy of vaccines leading to non-vigilant behaviors. • Handling of COVID-19 vaccine wastes (i.e. syringes, vials, PPEs, etc.); Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 88 • Public safety, including a pharmacovigilance system and Feedback and Grievance Redress Mechanism (FGRM) in place to report adverse effects in a timely manner; • Patients’ rights and consent processes for vaccination, particularly amongst populations who are skeptical and/or refuse vacc ination. An addendum to the environmental and social system assessment (ESSA) will be carried out to assess the above risk variables, on the basis of which additional measures to manage any significant gaps will be identified and agreed between the World Bank and MOH. The addendum will build on the ESSA of the parent program Indonesia Emergency Response to COVID-19 Program (P173843) and the current ongoing program: Indonesia – Supporting Primary Health Care Reform Program (I-SPHERE, P164277). Key results and findings of the initial screening: Initial screening was carried out based on the proposed result areas and inclusion of potential activities within each area. Further assessment, including stakeholder consultations, will be conducted during the Program preparation. - The activities planned under this P4R will not have significant adverse impacts that are sensitive, diverse, or unprecedented on the environment and/or affected people. The AF may include financing for cold chain facilities, vehicles and other logistics infrastructure as well as capacity building for frontline delivery workers at the request of the GoI. No adverse impacts to natural habitats, physical cultural property, natural resources are not likely since expected physical investments will be small-scale in nature; - Medical waste management and community health and safety issues related to the handling, transportation and disposal of hazardous and infectious medical wastes. This includes wastes resulting from vaccine delivery such as sharps, vials and the disposal of expired vaccines. Vaccination will likely take place in the existing hospitals and community health centers ( Puskesmas), which may be constrained in terms of waste-handling capacities. There are available guidelines from Ministry of Health (MOH) and Ministry of Environment and Forestry (MOEF), however, the increasing volume of waste, limited treatment capacity and lack of supervision due to the strains resources during this pandemic may increase the potential environmental risks—especially in the regions outside Java, as most of Indonesia’s hazardous waste treatment facilities are located in the island. - OHS risks for medical workers and staff related to the overall administration of COVID-19 vaccination. The risk includes possible exposure to infectious diseases which require additional protective gear for medical health workers. - Community health and safety issue related with vaccine safety which require end-to-end supply chain and logistics management systems for effective vaccine storage, handling, and stock management—including rigorous cold chain control - The availability of supplies, vaccine distribution and administration capacities will likely influence targeting and prioritization, which may leave high-risk population groups with no access to vaccination underserved. Individuals from low socio-economic status may be left out, particularly if distribution and targeting is weakly monitored (i.e., illegal sales of vaccines). Going forward, targeting must consider reduction of COVID-19 deaths, easing the strain on the healthcare system and supporting essential functioning of the society, in accordance with the existing global guidelines (such as WHO and CDC), scientific evidence, and expert advice. - Identification of individuals belonging to priority groups will require significant efforts to consolidate existing population databases, including SIAK (Population Registry) of Ministry of Home Affairs, DKTS (Unified Database) of the Ministry of Social Affairs, BPJS registry, etc. Population targeting may need to involve state apparatus at its lowest level (i.e., village) to update their population registries. Further, the development and use of the population registry for COVID-19 vaccination must consider the protection of individual privacy. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 89 - There is a considerable gap between regions/provinces/districts in Indonesia with regard to their capacity to distribute vaccines, which reflect the strength of the healthcare system in general. As such, even with an updated and accurate registry of prioritized groups, vaccines may not reach individuals due to logistical issues (e.g., lack of cold storage and transportation) and the lack of trained healthcare workers to administer the vaccines at service delivery points. - There may be hesitations among the general populations to be vaccinated due to concerns about the efficacy and safety of the vaccines. While individual informed consent is an imperative part of vaccination, public health risk measures including in times of emergency will likely supersede individual preferences. Going forward, GoI needs to assess this risk and to develop strategies to assure the general public and seek public and individual informed consent. - In responding to the above concerns, a robust communication strategy to educate and encourage public discussion, solicit feedback, engage mass media, and convey correct information (including changes in plans and how decisions are made) will be critical to support public buy-in and confidence. This would require transparent decision-making processes and accessibility to information. An accessible public complaint and grievance mechanism should also be set up and be informed to the public. Further, since the efficacy of the vaccines and their side effects may not be fully understood at the time of their administration, ensuring a pharmacovigilance system and Feedback and Grievance Redress Mechanism (FGRM) will be critical for public health safety. Institutional Capacity to manage environmental and social risks: MOH will remain as the implementing agency for the Program, with the arrangements to be slightly adjusted to include MOH’s Immunization sub - directorate. Overall coordination responsibility within MOH remains with the Secretary General ’s Bureau of Planning and Budgeting. The parent program’s implementation program was rated satisfactory in the last Implementation Status Report (ISR) of August 23, 2020 and the Program demonstrate good progress during the mid-term review. The directorates responsible for managing environmental and social risks are expected to remain the same and any additional implementing agencies will be assessed as part of the ESSA addendum. The Program Implementation Unit has been coordinating effectively and the program management structure and coordination mechanism was established with a Ministerial decree as required, coordinated by the MOH’s Bureau of Planning. During the last MTR mission, the team noted there has been good progress with some areas for improvements in the implementation of environmental and social Program Action Plan (PAPs) on infection control, medical waste management, public risk communication for patient safety, and personal data protection. The directorates responsible for the implementation of the PAP have also been coordinating with other key stakeholders to implement the required actions, including with other directorates in MOH or with other ministry and agencies. In addition to the COVID-19 Emergency Response PforR, MOH is also implementing a World Bank-funded PforR, namely the Indonesia – Supporting Primary Health Care Reform Program (I-SPHERE, P164277), which largely focuses strengthening a primary health care (Puskesmas) accreditation system and disease control and environmental health, both communicable and non-communicable diseases. It is expected that this on-going initiative will complement COVID-19 vaccination since Puskesmas will likely be the main service delivery points. Table A: Preliminary Risk Matrix Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 90 PDO Additional Result Expenditures E&S Effects Risks Indicators (AF) The overall GoI’s The overall environmental and The environmental and social risk is deemed to be To prevent, Improving hospital and program costs is social outcome is expected to substantial. There is a likelihood the Program detect and health system readiness, estimated US$ be positive. The PforR is would lead to some E&S consequences, but the respond to including the quality of care: 1.9 billion, of expected to strengthen health risks are predictable and can be managed through the threat • Puskesmas and which US$250 service system response, risk management measures. The current strain posed by Posyandu services for million is including: 1) improving capacity in responding to the pandemic may COVID-19 essential maternal health financed by the hospital and health system contribute to the possibility of the program may and and other services parent program readiness, including the quality not achieve its E&S operational objectives or strengthen remain uninterrupted in and US$ 500 of care; 2) Strengthen public sustain the desired E&S results. national at least 90% locations million will be health laboratory, surveillance systems for financed by this and supply chain system; and Risk areas of concerns under AF include a) public health additional 3) Enable communication and Occupational Health and Safety (OHS) and preparedness Strengthening public health financing coordination for emergency community health and safety related to the overall in Indonesia. laboratory, surveillance, and response. administration of COVID-19 vaccination, supply chain systems: including potential contacts and exposure with • Assessment of gaps in In the longer-run, the PforR high risk population groups, perceptions of cold chain capacity for also seeks to strengthened efficacy of vaccines leading to non-vigilant storage and distribution human capital and nation behaviors; b) Environmental pollution and of incremental vaccines systems for public health community health and safety issue related to the is completed preparedness for future handling, transportation and disposal of COVID- • Pharmacovigilance resilence 19 vaccine wastes (i.e. syringes, vials, PPEs, etc.); system in place c) community health and safety issue related with • ICT-enabled remote vaccine safety which require end-to-end supply temperature monitoring chain and logistics management systems for deployed in the vaccine effective vaccine storage, handling, and stock cold chain management—including rigorous cold chain control; d)public safety, including a pharmacovigilance system and Feedback and Enabling communication Grievance Redress Mechanism (FGRM) in place and coordination for to report adverse effects in a timely manner; d) emergency response patients’ rights and consent processes for • Population targeting/ vaccination, particularly amongst populations who prioritization plan are skeptical and/or refuse vaccination. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 91 • Halo Kemenkes citizen There are risks of social refusal for vaccinations information services and some sub-national governments are suitably updated contemplating to introduce punishment or sanctions for people who refuse to be vaccinated. Vaccinations under PfoR should primarily use a pursuasive approach. These potential environmental and social risks may likely be exacerbated by lack of capacity to contain COVID-19 infection due to the country’s strained healthcare and other supporting system during this pandemic. While it is acknowledged that under the pandemic situation the government will need to thread and balance carefully the human wellbeing objective (of reducing COVID 19-related deaths and morbidity) and the objective of economic recovery especially in making decisions about prioritized groups, there are concerns that the government may focus on economic recovery more than public health goal. There may be trade-off but there are also ways to reconcile the two objectives. Prioritizing healthcare workers, essential sectors, and vulnerable populations may help to reduce the number of deaths and severe illnesses, to ease the strain on health system, and at the same time contribute to economic recovery. Under the parent PforR, MOH has demonstrated good progress in the implementation of E&S PAPs of the parent program, which will need to be maintained as part of the AF. A robust strategy for public communication and consultation including engagement with stakeholders and mass media should be developed Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 92 as early as possible. Regular and routine dissemination sessions to public and community should also be conducted to provide assurance, promote compliance, and encourage public oversight. Further, a clear division of responsibilities and accountability lines, between MoH and other relevant ministries as well as sub- national governments should be defined and agreed in order to improve coordination and to increase the effectiveness of the program. An ESSA addendum to further assess the existing GOI’s systems, resources and capacity (both at the national and sub-national levels) to manage E&S risk under the AF will be conducted and appropriate mitigation measures agreed with MOH based on this addendum will be used to update Program Action Plans. The draft addendum is expected to be available by appraisal. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 93 ANNEX 6: Minutes of Stakeholder Consultations 1. A Commisioner at National Commission on Elimination of Violence Against Women (24 November 2020) - Only a handful of districts/cities have a considerably good databases of people with disability. In other districts, Dinas Sosial is tasked with the recording of people with disability but this register is rarely updated. The same observation about lack of accurate and updated data was also made about databases owned by disabled person organizations (DPOs). The lack of disability-aggregated data does not mean that people with disability are not registered in any government’s database. Like other citizens, most people with disability have been registered in at least one government’s database that is SIAK through their ownership of KTP and KK. - People with disability are disproportionately affected by the pandemic through various pathways. First, some people with disabilities who are dependent on other people for their everyday life and those who live in assisted life facilities such as panti, may be more exposed to infection. As disability is closely related to poverty, the pandemic also brings negative economic impact on people with disability, for instance blind people who disproportionately represented in masseuse service. - There are concerns around vaccination safety for people with disability whose disabilities are related to medical condition such as hormone irregularities, diabetic, and people diagnosed with cerebral palsy. Furthermore, not all people with disability have their disabilities medically diagnosed making it difficult to ascertain such potential risks. - People, including children, with disability also still face barriers in accessing health care. The lack of disability-friendly facilities (such as ramps, guideblocks, sign interpreters) is one of the factors. Futhermore, there is still a deep and prevalent perception within community that regards people with disability as sick people. This perception may prevent another obstacle for people with disabilities from accesing vaccination since as sick people they are perceived as not needing preventive measure such as vaccination. - Providing the correct information early on is key to increase trust among people with disability regarding the safety and efficacy of the upcoming vaccines. Dissemination of information needs to be channelled across various mediums (e.g. TV, social media, podcasts, radio) and formats to ensure accessibility for all spectrum of disabilities (e.g. visual and written for deaf, audio for blinds, etc). Engagement with religious leaders and disability activists, including well-known disabled-people organizations such as PPDI, HWDI, Gerkatin, Pertuni will be an important strategy to provide assurance and credibility to government’s messages. - The same principle of employing as many channels of communication as possible is also applicable in regards to feedback and grievance. Directly, individuals should be able to reach the government and convey their complaints through various mediums and receive official response immediately. Existing institutions that traditionally play the role of ‘watchdog’, such as Ombudsman, Komnas HAM, Komnas Perempuan, also needs to be engaged by the government. 2. Provincial Office of Health, DKI Jakarta (26 November 2020) - As per Presidential Regulation on Covid19 Vaccination and Minister of Health Regulation No. 12 of 2007 on Immunization, the central government plays a central role in vaccination program. Their roles cover procurement of vaccines and other consumable instruments as well as the cold-chain and cold storage. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 94 - The provincial government will assist the central government in the rolling-out of covid19 vaccines. Their roles include the mobilization of healthcare personnel, preparation of the venue/location preparation, transportation, warehousing and security. - Currently, the provincial government is documenting their existing human resource (trained healthcare worker and administrators), the available coldstorage (public and private), as well as preparing the communication and education strategy for wider public. The provincial government has also trained 130 vaccinators for all Puskesmas in Jakarta and they will continue training for vaccinators at private health service as well as the administrators. - Since October provincial government of Jakarta has started their own database updating to develop a roster of eligible individuals for vaccination through dasa wisma (which includes data on individuals under PBI, of productive age, and individuals with comorbidities). However, recently, the central government informed that the register will be given top-down from the national level. The list will be developed by compiling several national databases such as P-CARE (managed by BPJS that lists all JKN members, including PBI-APBD), SISDMK, SIAK, and other institutional registries as well as data from cellular operators. - The top-down identification and targeting of eligible individuals raised concerns around inclusion and exclusion errors as there are risks that national-level databases do not reflect on the ground situation. It is still unclear what will be the mechanism in place when there’s a discrepancy between the two registers (central versus local government). There is also no information if there will be contingency in forms of vaccines buffer for local governments to cover for eligible individuals who are not on the list. Not only this will be important for people who are not on the grand roster (from national government) but also for eligible people who might be registered in district/city or province other than where they are currently residing. - Another point for clarification is the nature of vaccination programs. Will the vaccines be compulsory? If yes, to whom? The provincial government has just issued a new provincial regulation that stipulates monetary sanction for residents who refuse to be part of government’s pandemic response including 3Ts and vaccination. However, the details of this sanction (e.g. who are obligated to take the vaccines and who are only recommended to be inoculated) are still being discussed and will be published through a governor regulation. - In relation to the previous point, there are plans to make commercial vaccines available in the market. While this is a good measure to ensure wider access to vaccines without burdening the national budget, this plan comes with certain risks. First, the availability of commercial vaccines means that vaccination for wider public is not compulsory. Second, the government needs to regulate the market to ensure the availability and affordability of the vaccines, for instance by determining and monitoring the ceiling price as well as by stringent criteria for licensing. Finally, the public communication strategy needs to include public assurance about the efficacy and safety of the subsidized vaccines distributed through the government’s program. For instance, the provincial government of Jakarta plans to not use the word ‘free’ as it connotates with low quality and left-over vaccines. - In regards to public communication, the provincial government appreciates the efforts of the National Task Force through Kominfo in relaying information on covid19 vaccination early on. The provincial government is now preparing their KIE (communication, information, and education) materials to be rolled out at least 1 month before the actual vaccination. The main message is to communicate the known risks and to convince the public that the vaccines are safe and effective. The are also needs to develop specific campaign to bust certain/dominant rumors and misinformation regarding Covid19 and its vaccines. It is, however, acknowledged that providing the correct first and early information is much more effective than correcting misinformation circulating in the community. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 95 - The provincial government will collaborate with various stakeholder such as Kominfo (they have special budget allocation for TV ads and blast) as well as digital and conventional mediums such as Jakarta Smart City platforms. The campaign will provide information on the price of each vaccine and will simulate the process of vaccines handling to help assuage any suspicion and mistrust. Engagement with ITAGI and other professional association will also be sought to provide public with experts reassurance. One of the informants mentioned that during the most recent nation-wide immunization program (MR vaccination), there wasn’t a significant refusal among population in Java island while outside Java the uptake of the vaccines was lower due to the rumor of the MR vaccines being haram. - In regards to FGRM, the provincial government will mobilize their existing channels such as JAKI, CRM, and direct complaints (through hotlines). These FGRM platforms have been linked to all SKPDs and the SKPD’s performance to handle complaints and settle grievance are part of performance indicator both for the institutions and the leaders. It is, however, unclear whether these local platform are or will be linked with national FGRM mechanisms, and if so, how the communication and accountability pahways will look like. - As any covid19 vaccines will be distributed through EUA, it is important to detect any adverse event following immunization (AEFI) and to determine the cause and whether or not such adverse events are correlated with or caused by the vaccines. Indonesia has already a mechanism in place to handle AEFI through experts commission on immunization at national level. 3. Multi-stakeholder forum: the Center of Epidemiological and Surveillance Research, University of Indonesia and Center for Indonesia’s Strategic Development Initiatives/CISDI (10 May 2021) - The national COVID-19 vaccination road map should aim for decreasing COVID-19 morbidity and mortality, and be based on the transmission risk. Priorities should be given to the population groups that geographically and demographically show rapid or widespread transmission of COVID-19, instead of the populations with higher economic contribution. This proposed road map could give more effective protection with the vaccine limited stock. As a model, DKI Jakarta province is now targeting elderly, and low-income community in densely populated areas. - In view of SDG3’s credo: Leave no one behind, Indonesia’s vaccination strategy must articulate the commitment and the strategy to reach vulnerable and marginalised groups, and perhaps even redefining the groups, considering the current/unprecedented pandemic context, such as job seekers/unemployed youth, as well as those who are vulnerable to gender-based and domestic violence. - A specific vaccination plan that accommodates the vulnerable groups is to be developed by the Government of Indonesia (GOI). Central and local governments need to review the practicality of the community registration or vaccination procedure, ensuring that those without the National Identification Number (NIK) are also eligible for COVID-19 vaccination. - Double vaccination is the concern that pushes the need for NIK as the requirement for vaccine eligibility. However, it is highly improbable that a person volunteers for double vaccination. Apart from the NIK, COVID-19 vaccination could use the confident population and civil registration data (Dukcapil), or requires those without ID to provide information/evidence of name, age, and home address. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 96 - Based on a quick CISDI’s informal interview, Puskesmas in Jawa Barat Province uses bottom -up data collected by cadres to identify COVID-19 vaccination targets, due to perceived data gaps/inconsistencies available in the top-down/existing system (including the MOH’s family-based health program, PIS-PK) in Puskemas. CISDI will share with the World Bank the report of CISDI’s Puskesmas Readiness Survey, an online rapid survey that focuses on the supply side of COVID-19 vaccination. - The COVID-19 vaccination process provides an opportunity for civil registration and data collection for adult immunisation target. The GOI should explore the interoperability of this proposed data collection with the primary care data system, hence optimising primary health care’s contribution to a robust data management system. - Vaccination activity should also be a communication channel where the members of the community get further education or are reminded about the actions to take to prevent COVID-19 transmission. Public messages should be more consistent, particularly across government institutions. - For wider and higher coverage, vaccination is to be made available in public venues, in addition to health facilities. The community could host a vaccination activity and support outreach activity to ensure that the elderly, people with disabilities, and other disadvantaged groups, are vaccinated. 4. Multi-stakeholder forum – waste management discussion: Nexus3 Foundation, Greeneration / Waste4Change, Yaksa Pelestari Bumi Berkelanjutan (YPBB) Bandung (10 May 2021) - The availability of medical waste processing facility in Indonesia remains the biggest challenge in the overall management of medical waste in the country. The possible rise in medical waste from vaccination activities raised an additional concern on the management of the waste, including the possibility of suboptimal incineration process that could create additional waste management issues. - The number of medical waste processed in the treatment facilities can be minimized through proper segregation of hazardous and domestic waste at source in the healthcare facilities. Capacity building for healthcare workers should be considered to ensure the segregation is conducted effectively at facility-level. Specific on vaccination activities, the minimization efforts can also be done through the effective implementation of procedures to distribute and store the vaccines. The efforts can minimized the waste generated by preventing vaccines wastage due to improper logistics management. - The waste management technology in Indonesia is currently heavily dominated with the use of incinerators, although the MOEF regulation no. 56/2015 allows the use of other technologies such as: autoclaves, microwaves, and irradiation among others. The use of incinerators posses additional concerns, especially the suboptimal operations that could lead to air pollution. There is a need for capacity building to the relevant agencies and incinerator operators on the ideal specification and operational condition of the incinerators used to manage medical waste so as to ensure the proper equipment are installed and operated properly. - Through the circular letters and waste management guidelines during the pandemic (including for vaccination activities), MOEF and MOH also suggested the use of autoclaves to manage COVID- 19 related waste. The use of this technology is relatively more environmental-friendly as it will not produce air and water emission from the process, as compared to incineration. However, there are several hurdles in promoting the use of other technology (like autoclaves) in the country. One of which is the need to further treated the output from autoclaves as hazardous waste. The current regulatory regime defines the output of autoclaves as hazardous waste so it has to be further treated Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 97 through other hazardous treatment facilities. It is understood that the output from autoclaves should not be categorized as hazardous waste and should be treated as domestic waste. Redefining the output of autoclaves can help easing the burden to the current hazardous waste management system in the country and at the same time promoting the use of alternative technologies other than incinerators. Another possible hurdle that could also hinder the adoption of other alternative waste management technology such as autoclaves is the complicated and unclear permitting process from the MOEF. - There is an opportunity to further improve the current regulations and/or guidelines on the management of used syringes (sharps) from vaccination activities by using needle crushers. Currently, the regulations and guidelines prescribed the use of safety box to temporarily store the used sharps before sending the wastes for further treatment. The use of safety box aims to prevent sharp injuries and nosomical infection to the workers during vaccination, as well as waste collection/transport/treatment activities. Needle crushers can be used to replace the safety box and act as an onsite treatment during vaccination to further minimize the risk of sharp injuries during the vaccination and/or waste management activities - During the pandemic, there are several cases of improper disposal of medical waste to the environment and/or domestic landfill. This highlights the importance of enforcement from relevant authorities on the implementation of hazardous waste regulations in the country. Although the enforcement authority mandated to MOEF, MOH should also consider other efforts apart from capacity building to ensure the proper implementation of these regulations. One of which can be through internal audits. - Further, for the overall improvement of healthcare waste management system in the country, MOH should consider providing specific guidelines in the management of medical wastes. This can be in form of ministrial regulation. The regulation could provide more clarity to the healthcare facilities on the management of hazardous waste and supplement the current MOEF regulation with a more practical approach within the current regulatory regime. Similar approach was observed for withdrawal of mercury containing medical devices, in which MOH issued a specific regulation to guide healthcare facilities on this issue. 5. Multi-stakeholder forum morning session: (18 May 2021) Participants: • Indonesian Anthropology Association (Asosiasi Antropolog Indonesia) • Alliance of Indigenous Peoples of the Archipelago (Aliansi Masyarakat Adat Nusantara/AMAN) • Center for Indonesia's Strategic Development Initiatives/CISDI • NGO Forum on AIDS Care (Forum LSM peduli AIDS) • Alliance of Women with HIV/AIDS (Ikatan Perempuan Positif Indonesia) • NGO Inti Muda Indonesia • NGO Jaringan Gaya Warna Lentera Indonesia (GWL-INA) • Alliance of People living with HIV (Jaringan Indonesia Positif) • National Commission on Violence against Women (KOMNAS Perempuan) • Nitisara Indonesia • NGO Organisasi Perubahan Sosial Indonesia • Perkumpulan Keluarga Berencana Indonesia (PKBI) • Persaudaraan Korban NAPZA Indonesia • Center on Child Protection and Wellbeing (Pusat Kajian dan Advokasi Perlindungan dan Kualitas Hidup Anak/PUSKAPA, University of Indonesia) Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 98 • Pusat Pengajian Islam Universitas Nasional • Puskesmas Toapaya • Red institute • Rumah Cemara • Parahyangan University • NGO Yayasan FKBP • NGO Yayasan Hidup Positif • NGO Yayasan Intermedika Prana (YIM) • NGO Yayasan Karisma • NGO Yayasan Kasih Suwitno • NGO Yayasan Kemitraan Indonesia Sehat (YKIS) • NGO Yayasan Kusuma Buana • NGO Yayasan Orang Tua Peduli • NGO Yayasan Pelita Ilmu • NGO Yayasan RESIK • NGO Wahana Inklusif Indonesia The following points are proposed to improve inclusivity, access, and equity of the COVID-19 vaccination program: - solution to ensuring that health workers could simultaneously reach the targets for maintaining the essential health care and conducting COVID-19 response and vaccination, considering the potential overwhelming workload; - provision of more vaccination points, additional to one or two health facilities at villages and subdistricts; and identify and cater for supporting needs for a certain population, such as transportation to and from the vaccination points for the vaccinated persons and their companies/caregivers, and free CD4 test for people living with HIV/AIDS (PLWHA); - an integrated, intersectoral collaboration that minimizes conflicting policies and activities; consistent data and information across sectors as well as central, provincial and district governments; - regular evaluation, and adjustment of communication strategies and activities, involving different scientific fields, including psychology; - more strategic, intensive, and extensive communication and outreach activities, particularly in villages and the communities, to: a. fight misinformation b. improve trust in government, local authorities and health professionals c. provide correct and positive information on safe and halal vaccine d. convince the members of the community to get vaccinated e. emphasize equality and inclusivity - improved capacity of health workers, government officials, cadres and other communicators in communicating the correct information - tailored communication and outreach activities to cater for the needs of and provide access for, among others: a. ethnic communities with unique traditions/beliefs b. people living in difficult to reach areas Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 99 c. people with disabilities d. people without the Single Identity Number (NIK) e. people without permanent address/nomadic community f. LGBTQI individuals g. The elderly - increased and more diverse communication channels, prior to vaccination, at the community level; increased mobilization of various communities and involvement of prominent community figures, including the communities of people with disabilities, people living with HIV/AIDS (PLWHA), and LGBTQ; - plan to improve health workers’ understanding of the importance of allocating time to communicate with the members of the community to address their concerns and misperceptions; - clear, detailed, and local-/context-sensitive information on: a. COVID-19 vaccine and vaccination b. the pros and cons of getting vaccinated c. COVID-19 vaccination/vaccination plan for pregnant women d. reporting adverse impact following immunization (AEFI) e. reporting harassment and misconducts f. legal rights concerning AEFI g. data privacy - mechanism to prevent and to report harassment and misconduct, along with the mechanism for regular monitoring and reporting; - clear information and procedure for people with co-morbid and other medical conditions to increase vaccine acceptance/uptake; plan to monitor the implementation of the procedure by vaccinators, administrative staff, data administrators and health facility managers; - communication to encourage the submission of correct and transparent information for vaccination registration and administration, to prevent potential AEFI; - clear and strict confidentiality/data privacy protocol, ensuring that medical status and data submitted during the vaccination procedure is treated with high discretion and does not instigate stigma, discrimination, repercussion, and other negative consequences; and plan to ensure that the protocol is adhered to, in order to avoid the submission of false information due to the lack of trust in the management of personal data; - mapping of and prioritization of people living in disaster-prone areas, considering the inability to follow the health protocol, post-disaster; - procedure/guidance/plan to improve the planning and management of vaccination activity in the vaccination venue, comprises procedures for: a. preventing COVID-19 transmission; b. people with compromised immune system; c. scheduling, ensuring well-calculated time management/scheduling to avoid missed appointments and financial loss. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 100 - enhanced pharmacovigilance and clear mechanism to ensure transparency, addressing the concern about the safety of the new vaccines; - collaboration of ministries and government institutions, such as the Community and Village Empowerment Office, to find a solution to NIK and mechanism for those without NIK; and using the vaccination as the opportunity to register people without NIK. 6. Multi-stakeholder forum morning session: (18 May 2021) Participants: • NGO Kebaya Yogyakarta • GWL INA • Alliance of People living with HIV (Jaringan Indonesia Positif) • NGO HIVOS • NGO Yayasan Srikandi Sejati • NGO Yayasan Kasih Suwitno Participants noted several issues pertinent to the current vaccination program. These are summarized as follows: - Barriers to access health service or vaccine a. For many marginalized groups, the use of National Identity Card numbers as the only mean to record and access vaccine is a barrier. b. Access to social assistance support was also limited for people that cannot obtain National Identity Card. c. Legal and bureaucratic administrative barriers are existed to obtain an Identity Card, especially for indigenous communities and transgenders. For example, although ruling of Constitutional Court if Indonesia enables “believers of indigenous faith� are allowed, in practice there are discrimination and stigma for marginalized groups. d. Access to reach public administrative record office are difficult in some part of Indonesia (transport & distance), and process to create a citizenship record might take time and cost if not simplified. e. Stigma and discrimination of certain groups have even made them unable to access public health system/essential service. For example, allegedly refusal of people living with HIV in Wisma Atlet (Covid19 Emergency Hospital) with no special need of specialized HIV medical care. f. For people who are accessing the Anti-Retroviral Treatment (ART) or Hormone Replacement Therapy (HRT), there are hiccups during pandemic in relation to irregular service and low supply of medicines. - Insufficient public communication related to several issues below a. Vaccine safety and if its halal or not b. Possible vaccine side effects, especially those who are immunosuppressed or are taking ART or HRT c. Vaccine implementation, especially around scheduling and eligibility. Many cases in the community for people who came to the vaccine hub and being rejected without good explanation for why they are ineligible. Vaccine eligibility must be communicated more to the public. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 101 d. Public communication is needed on the management of domestic waste that are related to health prevention such as mask and gloves. - Participants inputs on the way forward are a. emphasizing on the public communication that is catered to the marginalized groups, b. support the political will of the government to substantiate the rights of the marginalized group for equal access to vaccine c. ensure the essential health services that are needed by the marginalized groups are not overlook, ensuring the regular delivery of service as well as the logistical side. - World Bank noted efforts (cautiousness, proper process) of the government to ensure the safety of the vaccine. For example, to stop one batch of AZ after reports of side effects. However, the public communication may need improvement. - Also, the government has considered strategy to use this vaccine momentum to work together with public administration office to identify groups who are eligible for citizen ID. - World Bank took notes of the inputs and will discuss it further with MoH. Furthermore, World Bank would like to receive more inputs by the public via emails before the negotiation process with MoH. Indonesia – Emergency Financing Support for COVID-19 (P173843) Page | 102