The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 28-Jun-2021 | Report No: PIDA32121 Jun 28, 2021 Page 1 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Angola P176630 Angola COVID-19 Strategic Preparedness And Response Project Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) AFRICA EAST 11-May-2021 06-Jul-2021 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Angola Ministry of Finance Angola Ministry of Health Proposed Development Objective(s) The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Angola. Components Emergency COVID19 Response COVID19 Immunization Community engagement and risk communication for demand creation Project Implementation and monitoring PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 150.00 Total Financing 150.00 of which IBRD/IDA 150.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 150.00 Jun 28, 2021 Page 2 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Environmental and Social Risk Classification Substantial Decision The review did authorize the team to appraise and negotiate Other Decision (as needed) The project is being processed under Condensed Procedures (Paragraph 12 of Section III of the IPF Policy for Project Preparation) approved by the Country Director on June 9, 2021 in response to the memo submitted by the task team. B. Introduction and Context Jun 28, 2021 Page 3 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Country Context 1. Angola is facing the greatest challenges to the country’s prosperity since the end of the civil war. As Africa’s eighth largest economy, with a wealth of natural resources, Angola has the potential to generate significant economic growth and to reduce poverty. After the end of Angola’s 27 year-long civil war in 2002, the economy prospered thanks to revenues from vast oil reserves, with gross domestic product (GDP) per capita doubling from US$ 2,000 in 2002 to more than US$ 5,000 by 2014. The benefits of that growth were not broadly shared however, resulting in a high level of inequity, with a Gini coefficient of approximately 0.51. By 2018, an estimated 32 percent of the 30.2 million Angolans lived in poverty.1 Heavy reliance on oil revenues and a lack of economic diversification, with agriculture and services remaining particularly untapped, have stymied broad-based growth and created few jobs, especially for young labor market entrants. 2. While the World Bank has been engaged in Angola for about 30 years, the dual shocks of oil price reduction and COVID-19 have dramatically changed the country context, the country’s need for support, and thus the partnership between Angola and the World Bank Group (WBG). Angola’s oil-based growth model has not been inclusive or poverty reducing—even during the period of high oil prices (2005-14) when Angola recorded rapid economic growth. Depressed oil prices have led to a five-year recession, recently further exacerbated by impacts from the COVID-19 pandemic, resulting in an increase in poverty and a decline in human development indicators. The government that assumed office in late 2017 is committed to establishing a more sustainable and inclusive growth model and substantial progress has been made in recent years towards reforming the economy. 3. Angola is currently facing multiple crises, including severe, persistent droughts, diverse natural disasters, multiple infectious diseases epidemics — and now the global COVID-19 pandemic. This situation could increase the number of people vulnerable to food insecurity from 2.3 to 7.4 million. Access to water resources in Southern Angola is highly vulnerable to climate extremes; more than 35 percent of livestock have died. The structural causes of these drought impacts are poor rural water point governance (lack of monitoring, maintenance and repair systems, weak institutions) and lack of drought preparedness. Adaptation to climate change, with a focus on the south, and food security, are therefore emerging as priority areas for WBG support going forward. The health consequences are indeed dire, including an exacerbation of already severe food insecurity and acute and chronic malnutrition (especially in the southern provinces), adverse impacts on the ability to treat other prevalent infectious diseases, over-burdened health care services, and higher health expenditures. 4. Angola suffers from weak human capital, manifested in a Human Capital Index (HCI) of 0.37. This is largely due to persistent under-investment in social sectors and human capital but is also a result of Angola’s non-inclusive growth model. Fiscal constraints will limit increases in social spending over the coming years, though the government has made efforts to protect the budget and to build systems to increase the effectiveness and efficiency of social spending. As part of its IMF program, authorities have agreed on a floor for social expenditures, which was exceeded in 2020 and will likely also be exceeded in 2021. The Bank is engaged to strengthen human capital, including through a Development Policy Financing (DPF) supporting the establishment of a flagship poverty-targeted cash transfer program (Kwenda). In the health sector, the Bank supports the piloting of performance-based financing in selected provinces, with a view to extending the program based on results and lessons learned. In the education sector, a 1 World Bank, 2020. Angola: Country Partnership Framework. (Forthcoming). Jun 28, 2021 Page 4 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) forthcoming Girls’ Empowerment and Learning for All Project aims to improve learning quality for all and introduces a scholarship system to keep girls in secondary school, accompanying an ongoing Learning for All Project. 5. The coronavirus disease (COVID-19) pandemic hit Angola as it was attempting to recover from these shocks, taking a heavy toll on the economy. With a highly oil dependent economy, the decline in the oil sector and the price of oil is the main driver of the multi-year recession. COVID-19 related disruptions also contributed to the 2020 decline (especially in the second quarter). Driven by rapid currency depreciation (37 percent in 2020), inflation increased to 25 percent in January 2021, with food prices rising even faster, at 31 percent. Despite increased health spending, fiscal policy has remained tight, and debt exceeds 120 percent of GDP. In 2020, the government prioritized spending on health (which increased 40 percent) and social protection. Total public debt is estimated at 128 percent of GDP at the end of 2020 (up from 107 percent of GDP in 2019). Debt-to-GDP has increased continuously despite fiscal surpluses in 2018 and 2019 due to currency depreciation (close to 80 percent of public debt is denominated in foreign currency). With the sharp drop in oil revenues, the fiscal balance fell into deficit (estimated at 1.7 percent of GDP), but the primary fiscal balance remained in surplus in 2020. 6. The capacity to manage the epidemic together with the widespread deployment of COVID-19 vaccines will be at the core of a resilient recovery from the pandemic’s dual impacts on the economy and human development in Angola. The economy is expected to gradually pick up in the medium term, with the anticipated recovery of the oil price eliminating the fiscal deficit and reducing debt-to GDP beginning in 2021. However, much depends on the trajectory of the pandemic, and Angola’s capacity to contain it. Beyond the immediate health impacts of reduced mortality and local transmission, as vaccine coverage increases, scaling up vaccination can help accelerate the easing of containment measures, allowing for a more rapid recovery of economic activity and restoration of critical human development services. Jun 28, 2021 Page 5 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Sectoral and Institutional Context A. 7. Angola reported its first case of COVID-19 on March 21, 2020, and as of as of June 10, 2021, had reported 36,325 confirmed COVID-19 cases and 815 resulting deaths. Angola was one of the first African countries to adopt social distancing and restrictive measures starting with the closure of all airports to commercial flights from March 24, 2020. A state of emergency was declared on March 27, 2020, with domestic and international travel and circulation restrictions imposed nationwide. A Multisectoral Commission was set up to oversee implementation of the National Contingency Plan activities and COVID-19 related decisions. After a slow and steady increase in daily cases from March to September 2020, COVID-19 daily cases increased exponentially up to the end of October 2020, when the country saw a daily number of confirmed cases of 260 on October 27th. After two weeks of having a daily number of confirmed cases above 200, cases started to decline, stabilizing between December and January at 50 to100 cases, and since then to the beginning of March 2021, the average daily case count has been under 50 new infections (see fig 1). However, since mid-March the cases started to increase and by mid-May, roughly 250 cases were being registered per day, indicating a second wave of the COVID-19 pandemic in country. As expected, the epidemic curve for deaths has followed the epidemic curve for confirmed cases (see Fig 1). With the initial roll out of the COVID-19 vaccines as per the National Deployment and Vaccination Plan (NDVP), the country is trying to mitigate the health systems impact of the pandemic focusing on the individuals most at risk of severe disease and deaths. Fig 1. Angola, daily New Confirmed COVID-19 Cases and deaths, respectively, rolling 7-day average from March 2020- May 12, 2021 8. The COVID-19 pandemic and related socio-economic consequences are expected to adversely impact other key health priorities in Angola, such as Human Immunodeficiency Virus (HIV), malaria, and tuberculosis (TB ), as well as maternal, child and reproductive health and care for chronic illness. The impact will most likely arise from disruptions in the usual activities and services resulting from the mitigation strategies being utilized in response to the Jun 28, 2021 Page 6 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) COVID-19 epidemic. Containment and isolation measures have led to the scaling back of certain activities and care- seeking patterns, as well as reduced capabilities of the health system due to the high demand for the care of COVID- 19 patients. The pandemic has also led to interruptions in the supply of commodities because of domestic and international supply chain disruptions. It has also displaced financing for non-COVID health programs due to increased funding being directed to the health sector response to the COVID-19 outbreak. The impact on the HIV response is due to individuals being less likely to refill prescriptions, as well as an intentional scaling back of HIV services due to reduced funding to the program.2 The impact on TB could potentially arise from treatment being discontinued or delayed treatment initiation.2 The impact on malaria will be due to the disruption of long-lasting insecticidal net distribution and seasonal malaria chemoprevention activities, as well as a reduction in clinical case treatment by 50 percent.2 In high burden settings such as Angola, HIV, TB- and malaria-related deaths over the next five years may increase by up to 10, 20 and 36 percent, respectively, as compared to the situation without the COVID-19 pandemic. Beyond the above, the COVID-19 pandemic has impacted the provision of care to patients with chronic non- communicable diseases (NCDs) and coverage of routine immunization and maternal and child primary care services. According to a UNICEF led survey in February 2021, 51.2 percent of the people interviewed by phone had not accessed essential health services during the COVID-19 pandemic. The three main reasons for not seeking essential services were lack of funds to pay for services, low quality of care during the pandemic and the fear of exposure to COVID-19. 9. Angola’s recent experience in managing one of the largest yellow fever outbreaks and leading a massive nation-wide vaccination campaign, will be instrumental for the successful roll-out of an ambitious COVID-19 immunization plan. On December 2015 the first case of yellow fever was detected in Luanda among a migrant population (from Eritrea) eventually spreading country-wide to 16 of Angola’s 18 provinces, resulting in 884 confirmed cases and 121 deaths. The outbreak which lasted for seven months can be explained by the low yellow fever vaccination coverage of 48.5 percent among children aged 12-24 months reported in the 2015-2016 Demographic and Health Survey, coupled with a large susceptible population who were not infected in the previous smaller yellow fever outbreaks, along with high levels of Aedes aegypti mosquito infestation in both urban and rural areas. In April 2016, Angola started a country-wide vaccination campaign, initially as a reactive campaign and concluded in February 2018 as a preventive campaign. A total of 23.74 million individuals were vaccinated country-wide achieving a reported coverage of 91.4 percent. During the vaccination exercise there were many challenges: low previous experience implementing a massive vaccination campaign; shortages of qualified vaccinators; ensuring vaccine quality with a very large number vaccine doses being channeled through the logistical supply chain system; vaccine hesitancy (particularly among men from high socio-economic status); and last mile delivery in hard-to-reach populations. These challenges translated to the following lessons learnt that will be crucial for the success of the roll-out of the COVID-19 vaccine: strong political commitment and the presence of a high-level mechanism of emergency coordination at all levels enabled a more robust response; strong supply systems to ensure effective management of vaccines and reduce wastage; engagement with armed forces as an instrumental tool for swift, robust and effective mass vaccination campaigns with a pool of trained vaccinators as well the logistics and fleet infrastructure to transport the vaccines to the most rural areas; and risk communication and engagement was a key tool through which to tailor messages to groups to address vaccine hesitancy for the success of vaccination efforts. 2 Report 19: The Potential Impact of the COVID-19 Epidemic on HIV, TB and Malaria in Low- and Middle-Income Countries, https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-05-01-COVID19-Report- 19.pdf Jun 28, 2021 Page 7 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) 10. The COVID-19 vaccine deployment will build on the lessons of the yellow fever mass vaccination campaign . Angola still faces significant challenges in terms of national immunization coverage that is significantly lower than the World Health Organization (WHO) target of 90 percent. The COVID-19 pandemic has put further stress on sub-optimal vaccination systems and national immunization coverage levels are expected to have decreased in 2020 and likely in 2021. The proposed project will provide upfront financing to help the government purchase and deploy COVID-19 vaccines that meet the Bank’s vaccine approval criteria (VAC) and strengthen relevant health systems related to the government’s vaccine program that are necessary for a successful deployment of the COVID-19 vaccine. This will have a positive impact on routine immunization coverage by leveraging this opportunity and ensuring combined (routine + COVID-19) immunization campaigns, especially for hard-to-reach populations. C. Proposed Development Objective(s) Development Objective(s) (From PAD) The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Angola. Key Results (From PAD) • Percentage (%) of population vaccinated, which is included in the priority population targets defined in the national plan [disaggregated by sex]; • Number of COVID-19 designated hospitals with cryogenic oxygen tanks 11. The project beneficiaries include direct beneficiaries and, in the long-term, the population at large (32,097,670), who will benefit from decreased risk from contracting COVID-19 and other vaccine-preventable diseases, through deployment of the COVID-19 vaccine and strengthened systems for immunization. The project will directly benefit the target population of the Angola NDVP which includes a total of 15.5 million people to be reached. 12. The Angolan NDVP draws on the findings of the VRAF/VRAT 2.0 assessment and gap analysis, targeting the most vulnerable and at risk of severe COVID-19 infection. The Angola NDVP was approved and validated in the Partners Platform in February 2021. The Angolan NDVP targets a total of 15.6 million people (48.6 percent of the population) to be reached in two-phases. Phase 1 of the NDVP aims to reach 20 percent of the population (6.4 million people), with up to 12.8 million doses of vaccines to be provided by the COVAX-AMC Facility. Phase 1 of the vaccination strategy includes two stages. The prioritization process for the first stage of Phase 1 is based on the national epidemiological analysis and the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework which will target the most exposed groups such as first line health workers, people with an established diagnosis of a relevant co-morbidities, personnel of social services, including teachers and other exposed groups such as police, inmates, refugees, security personnel and public transport drivers estimated at 3 percent of the population. The second stage of Phase 1 represents 17 percent of Jun 28, 2021 Page 8 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) the population and includes the population 40-years-old and over, which have shown the highest morbidity and hospitalizations due to the high prevalence of comorbidities (obesity, diabetes, cardiovascular diseases). Even though the elderly has the highest lethality rates from COVID-19 and have the highest priority to be vaccinated, the Angola NDVP targets them under this second stage of Phase 1 due to difficulty in locating them given the geographical dispersion. Phase 2 represents an additional 29 percent of the population and expands the target group to include the population over 18 years old. Of note the highest incidence rates (incidence rates by age group) are in the 30 to 54-year-old age groups, which indicates that to reduce the transmission of this disease, the age strata younger than 40 years old have to be targeted in order to achieve immediate epidemiological impact on mortality and transmission. Table 3: Priority groups for vaccination Angola Population group Number of people % of population Phase 1 (20%) Stage 1 (3%) 1 Health workers 117,488 0.4 2 Social services and teachers 87,000 0.3 3 People with established diagnosis of comorbidities 417,000 1.3 4 Police, inmates, refugees 243,442 0.7 5 Public transport drivers’ and market vendors 98,000 0.3 Stage 2 (17%) 1 ≥80 years 96,799 0.3 2 75-79 years 129,071 0.4 3 70-74 years 221,096 0.7 4 65-69 years 345,619 1.1 5 60-64 years 500,999 1.6 6 55-59 years 676,983 2.1 7 50-54 years 879,435 2.7 8 45-49 years 1,102,633 3.4 9 40-44 years 1,503,969 4.3 Total Phase 6,419,534 20 1 Phase 2 (29%) Jun 28, 2021 Page 9 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) 1 35-39 years 1,466,929 4.6 2 30-35 years 1,749,756 5.5 3 25-29 years 2,100,625 6.5 4 20-24 years 2,549,011 7.9 5 18-19 years 1,317,879 4.1 Total Phase 9,184,200 28.6% 2 Total 15,603,734 48.6% D. Project Description 13. The project is designed to address key gaps identified in the readiness assessment and activities described in the Government’s National Plan for Vaccination Against COVID-19, while strengthening health systems that can increase COVID vaccination rates. Financing from this project will support the acquisition, management, and deployment of COVID-19 vaccines, including support to ensure effective utilization of vaccines received to cover priority groups. Financing will also strengthen health systems that enhance the COVID-19 response. 14. Thorough cold chain for COVID-19 vaccination assessments have been conducted to inform project design and cold chain needs at the Angolan EPI. The national vaccine deposit has one cold room + 2ºC + 8ºC of 123 m3 of liquid capacity and one freezer Room -15ºC to -25ºC of 70 m3 liquid capacity. For ultra-cold chain conservation -70ºC, 10 ultra-cold chain Freezers of 780 liters of storage capacity each are available. Additional 19 ultra-cold-chain freezers are in the process of arriving in the country and will be strategically distributed in the provincial capitals. At the provincial level, all 18 provinces have a cold room at least 7 m3 net except for the Province Cuando Cubango. All the provinces with cold rooms have a backup generator for electricity. For Cuando Cubango, additional cold chain equipment is included in the COVAX cold chain proposal. At the municipal level, the installed capacity of vaccination campaigns against polio will be used. To improve the municipal level cold chain storage capacity, a proposal for additional cold chain support at the municipal level from COVAX was submitted with the country logistic team. The Vaccination Program has four refrigerated vehicles for secure vaccine delivery in the country. In addition, private refrigerated vehicles will be rented during campaigns to distribute vaccines and other materials through the Central Procurement Agency for Medicines and Medical Supplies (CECOMA, in its Portuguese acronym). There is a long-standing cooperation with the Armed Forces to support the MOH such as in the yellow fever vaccination campaign. As articulated in the NDVP, the armed forces will provide support in the transport of vaccines in line with the plans presented by the NDVP logistics group. The transport of vaccines from municipalities to vaccination posts will be done utilizing long range cold boxes. Jun 28, 2021 Page 10 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) 15. Angola has been conducting in an iterative fashion its vaccine readiness assessment to identify gaps and options to address them, as well as to estimate the cost of vaccine deployment, with the support of international organizations (including WHO, UNICEF, and Gavi). This assessment considers the government’s vaccine deployment strategy, described below in Table 2 below. Considering the uncertainties related to the COVID vaccine market, including testing, approval, availability and pricing, which require flexibility and close monitoring and strong Bank support during implementation, the assessment will continue to be an evolving process and will be dynamically revised and updated as necessary to continue to improve project implementation. Table 2 - Summary of Vaccination Readiness Findings from the VIRAT/VRAF 2.0 assessment3 (April 14, 2021) Readiness domain Readiness of government Key gaps to address before (what has been done) deployment (gaps and how they are being addressed) Planning and A National Coordinating Committee (NCC) for COVID-19 vaccine To address the gap of waste coordination introduction with terms of reference, roles and responsibilities management tools and and regular meetings has been established and the body and its processes, support the leadership are accountable and functional. planning and procurement of waste management materials and equipment, to ensure A National Technical Working Group (NTWG) for COVID-19 compliance with protocols and vaccine introduction with terms of reference, roles and plans established. responsibilities and regular meetings has been established. Eight NTWG subcommittees have been established. The Angolan COVID-19 NDVP, with input from relevant bodies has been finalized and validated through the Partners Platform in February 2021. Identification and planning for the national vaccine access/procurement approach (e.g. COVAX Facility, bilateral purchase agreement, procurement through UN agency, African Union, self-procurement) is underway. The costs of items, due diligence mechanisms and an overall budget has been approved. Budgeting COVID vaccine program costs (vaccine, operating costs, HR and Define financial management capital costs) have been included in the government budget. The reporting system to ensure 3 A multi-partner effort led by WHO and UNICEF developed the Vaccine Introduction Readiness Assessment Tool (VIRAT) to support countries in developing a roadmap to prepare for vaccine introduction and identify gaps to inform areas for potential support. Building upon the VIRAT, the World Bank developed the Vaccine Readiness Assessment Framework (VRAF) to help countries obtain granular information on gaps and associated costs and program financial resources for deployment of vaccines. To minimize burden and duplication, in November 2020, the VIRAT and VRAF tools were consolidated into one comprehensive framework, called VIRAT-VRAF 2.0. Jun 28, 2021 Page 11 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Budget was finalized with development partner contributions management aspects of with a total cost of US$252.2 million. appropriations from the MOF/Treasury are in place. Regulatory All regulatory frameworks are in place, including: An expedited regulatory pathway for approval of COVID-19 vaccines, including timelines and maximum number of days. The Astra Zeneca/Serum Institute of India (AZ/SII) vaccine provided under COVAX was approved. However, the critical COVID-19 situation in India has put a strain on the production of the AZ/SII vaccine and is delaying the in-country vaccine roll out. Clarification from the national regulatory authority on the regulatory requirements, and documents needed for regulatory approvals of COVID-19 vaccines and related supplies. Regulatory procedures are in place for import permit of COVID-19 vaccines and related supplies, and identify the requirements and documents needed to import COVID-19 vaccines and related supplies, including for taxes and tariffs. Expedited import approval from appropriate authorities confirmed by WHO. Requirements and documents needed for release of vaccines are clear and there is a system in place to ensure COVID-19 vaccines can be released (lot release) in less than two days by reviewing the summary lot protocol only (testing is not required). Prioritization and Priority groups for the different vaccination phases have been Surveillance identified and quantified in collaboration with the NTWG subcommittee for prioritization, targeting, and COVID-19 surveillance to facilitate epidemiological data collection to record the vaccination status of infected persons using the existing COVID surveillance system. A real-time registration and vaccine roll-out monitoring system (ReDIV) has been developed and is being implemented nationwide. The system has allowed the registration of more than Jun 28, 2021 Page 12 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) 600,000 individuals from the priority groups and captured the vaccinated individuals (over 500,000) across the 18 provinces, with data disaggregated by sex, priority group, geographical location among other categories. Service delivery Protocols for infection prevention and control measures including Ensure existence of protocols adequate personal protection equipment (PPE) to minimize regarding consent to exposure risk during immunization sessions have been updated. vaccinations, process for agreeing to or refusing to be vaccinated, and measures to The details related to COVID-19 vaccine delivery strategies protect those that refuse to be leveraging both existing vaccination platforms and non- vaccinated are in place. vaccination delivery approaches to best reach identified target groups have been finalized to include vaccination sites and personnel. Measures to address the accounts of inefficient delivery platforms need to be developed to ensure the large gatherings at testing sites for prolonged periods of time (exceeding three hours) are eliminated. Training and Training plan developed for all personnel participating in the supervision vaccination campaigns. Training materials developed by WHO have been adapted and translated. Plans to safeguard the security of staff (e.g. during an emergency or major campaign) as well as security at the central and/or regional storage facilities and for products in-transit have been established. Virtual and/or in person trainings as outlined in the training plan with technical assistance from WHO have been undertaken. Monitoring and Appropriate institutional arrangements have been outlined and evaluation paper-based and/or electronic monitoring tools have been adapted to monitor progress and coverage among different at- risk categories and facilitate vaccine delivery and timely reporting. Measures are in place for data protection, and appropriate data governance regulation is in place. Jun 28, 2021 Page 13 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) As highlighted above, reDIV is monitoring a set of key indicators both on the registration of the eligible population as well as on the tracking and monitoring of the vaccinated individuals allowing for a real time monitoring system that ensures data transparency and visibility, mitigating the risk of elite capture and providing the key information for programmatic changes to overcome challenges of vaccine roll out and priority population coverage. Mechanism with multiple intake points to include grievance redress has been designed and is operational for feedback in relation to the vaccine program. Vaccine, cold chain, NTWG subcommittee for vaccine, cold chain & logistics has in logistics, place terms of reference and standard operating procedures to infrastructure coordinate COVID-19 vaccines and deployment of ancillary products. Key roles and responsibilities needed for vaccine and ancillary products deployment; collect and confirm contact information for key personnel and facilities have been mapped. Plan for infrastructure needs, including for energy (primary and back-up power, especially in cold chain), IT/communications (including internet connectivity) and water has been developed. Standard operating procedures (SOPs) or guidelines for collection and disposal of medical waste to the relevant stakeholders are in place. Vaccines will be purchased using different options to support the country’s needs for direct or advance purchase, including the use of the COVAX facility, the African Union (AU) AVATT initiative or the use of Bank Facilitated Procurement (BFP), where feasible. As mentioned above, the critical COVID-19 situation in India has put a strain on the production COVID-19 vaccines underscoring the country need to assess different purchasing options. Jun 28, 2021 Page 14 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Potential port(s) of entry, points of storage (stores), and fallback facilities in the country with their respective cold chain storage (2-8C, -20C, -60/70C) and transportation capacity for vaccines and ancillary products have been mapped. Strengthening and expanding the systems and protocols for tracking and monitoring the stock management and distribution of vaccines and key supplies through the Government's existing Vaccine Logistics Management and Information System (VLMIS - LOGISTIMO) has been budgeted and formally requested to be supported by current project Assessment of dry storage and cold chain capacity at all levels with regards to the COVID-19 vaccines characteristics has been undertaken Delivery and acceptance protocols and monitoring arrangements have been defined which will determine the investments in infrastructure and equipment needed. Safety surveillance Guidelines, documented procedures and tools for planning and conducting vaccine pharmacovigilance activities (i.e. AEFI reporting, investigation, causality assessment, risk communication and response) are available. Channels of data sharing mechanisms to share COVID-19 vaccine safety data and findings with relevant regional and international partner identified and secured. Adequate and trained human resources are available to conduct surveillance of events attributable to vaccination. Appropriate representation, well defined ToRs and training the AEFI committee to review COVID-19 Vaccine safety data (e.g., causality assessment of serious AEFI, clusters of AEFI, emerging safety concerns etc.) has been established. Jun 28, 2021 Page 15 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) A coordination mechanism between relevant stakeholders (NRA, EPI, MAH, MOH, WHO and others) for exchange of COVID-19 Vaccine safety information has been established. Provisions that require manufacturers to implement risk management plans and collect and report COVID-19 vaccine safety data to the NRA has been identified. Compensation schemes if there are unintended health consequences as result of vaccines, including no-fault liability funds, and associated policies are in place. Demand generation Developed key messages and materials for public Data collection systems, and communication communications and advocacy, in alignment with demand plan. including 1) social media listening and rumor management, and 2) assessing A demand creation plan (including advocacy, communications, behavioral and social data, are social mobilization, risk and safety communications, community being piloted. engagement, and training) to generate confidence, acceptance and demand for COVID-19 vaccines has been finalized and being implemented. Project Components Component 1: Emergency COVID19 Response (US$10 million) 16. Support to the COVID-19 response. This component will provide support to the GoA to respond to the COVID-19 epidemic during this current second wave of COVID-19 transmission which began in May 2021. It will build on the initial US$15 million financing support provided by the Health System Performance Strengthening Project (HSPSP) (P160948) for the COVID-19 emergency response. Support will be provided for the enhancement of disease detection capacities through provision of technical expertise, laboratory equipment and systems to ensure prompt case finding, confirmation and management as well as contact tracing, consistent with WHO guidelines in the Strategic Response Plan through two sub-components. 17. Sub-component 1.1: Case Detection, Laboratory Confirmation, Contact Tracing, Recording, Reporting (US$5 million): (i) strengthen disease surveillance systems and epidemiological capacity for early detection and confirmation of cases through the strengthening of the Rapid Response Teams (RRTs) namely through training and capacity building as well as purchasing electric vehicles to increase the RRTs fleet and streamline active surveillance activities; (ii) combine detection of new cases with active contact tracing; (iii) support operational costs for epidemiological investigation; (iv) strengthen provincial and municipal level risk assessments; (v) provide Jun 28, 2021 Page 16 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) on-time data and information for guiding decision-making and response and mitigation activities; (vi) strengthening the national laboratory diagnostic to conduct COVID-19 diagnostic tests and training of laboratory staff (selection for such trainings will be gender sensitive and the output of this activity will be tracked through a gender disaggregated indicator); (vii) in the mid-term, build capacity for handling key priority diseases, including disease outbreaks induced by climate emergencies, in accordance with WHO guidance and synergic to the investments made by the REDISSE IV project; (viii) purchase reagents, test kits, laboratory consumables as well as the necessary PPE equipment for adequate infection prevention and control practices. Additional support will be provided to strengthen health management information systems to facilitate recording and on-time virtual sharing of information 18. Sub-component 1.2: Health systems strengthening (US$5 million): Assistance will be provided to the health care system for preparedness planning to provide optimal medical care, maintain essential community services and to minimize risks for patients and health personnel, including training health facilities staff and front- line workers on risk mitigation measures and providing them with the appropriate protective equipment and hygiene materials. The project will support upgrading/refurbishment of health care facilities to increase COVID- 19 case management capacity at municipal level as well as ensure that adequate oxygen supply is ensured at all levels of the healthcare system including at municipal level. Refurbishment will also include equipping health facilities with solar panels and minor rehabilitation to reduce energy use such as improved sealing for windows and doors, use of reflective paint for cooling facilities, and use of LED lights. The project will support strengthening medical waste management in health care facilities in relation to COVID19 waste management the project will include procurement of equipment and training of staff. Special attention will be paid to waste management in flood-prone areas. Component 2: COVID-19 Immunization (US$130 million) 19. This component will provide financing to support the purchase and deployment of COVID-19 vaccines. This component includes three sub-components: support to strengthen the supply and cold-chain system, purchase of vaccines, COVID-19 vaccine program delivery. 20. Sub-component 2.1: Strengthening supply chain and cold chain (US$10 million): The following key activities will be financed: (i) reactivation of the national logistics working group with appropriate terms of reference and SOPs for the storage, distribution, transportation and use of COVID-19 vaccines, vaccine distribution planning using route optimization to minimize fuel use, vaccination materials, and treatment of vaccination waste; (ii) provision of SOPs for conservation, transportation, vaccination and guidelines for the collection and disposal of waste appropriate to local conditions; (iii) purchase climate friendly cold chain equipment at all levels (solar direct drive refrigerators and low Global Warming Potential (GWP) refrigerators), capacity and location of vaccine and material storage points, in relation to the characteristics of the COVID-19 vaccines received and fill the supply and logistics gaps identified; (iv) organize the central and provincial vaccine warehouses, creating conditions for the reception of vaccines and material, transportation logistics, cold chain and additional personnel necessary for Jun 28, 2021 Page 17 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) distribution to lower levels; (vi) implement the IOTA Platform's Cold Chain Temperature Management module; (vii) update the product list with the codes for the new vaccines, related materials and train in digital management of vaccine and material stock (IOTA) to the provincial and municipal staff of the 12 provinces in need and procure telephones for such monitoring of COVID-19 vaccine stock in real time; (viii) implement at 18 provincial and district levels the IOTA Vaccine Logistics Management Digital Platform (in six provinces the system is operating at provincial, districts and health facility level), expanding from approx..1,200 sites to approx..2,000 sites; and (ix) strengthen EPI’s fleet for service delivery through the purchase of electric vehicles. In addition, this component will finance maintenance of existing cold chain equipment, warehouses, vehicles, other logistics infrastructure, and refurbishment and maintenance of facilities to be resilient to climate shocks. 21. Sub-component 2.2: Procurement of COVID-19 vaccines and related consumables (US$90 million): In alignment with Board approved criteria, the World Bank will provide up to US$85 million to finance vaccine acquisition (mostly likely through the COVAX or AU/AVATT purchasing mechanisms). This aims to enable coverage of approximately 20 percent of the population (a two-dose regimen at an estimated $7/dose). This will complement COVAX AMC and other sources, as detailed in Table 3, to reach the Government’s current coverage target of 48.6 percent of the population. The availability and terms of vaccines remain fluid and prevents the planning of a firm sequence of vaccine deployment, especially as the actual delivery of vaccines is unlikely to be immediate. Rather, the proposed World Bank financing enables a portfolio approach that will adjust during implementation in response to developments in the country pandemic situation and the global market for vaccines. This financial support will be aligned with the NDVP, developed by the Government with support from WHO, UNICEF and GAVI. This will be accompanied by support under this component to acquire vaccination supplies (syringes and safety boxes), personal protective equipment for vaccinators, and related equipment for vaccine administration and infection prevention and control, including water and sanitation. 22. Sub-component 2.3: COVID-19 vaccine service delivery (US$30 million): This sub-component will support COVID-19 program delivery which, due to the complex nature of such a mass vaccination campaign, will include the following key activities: (i) vaccine targeting - the COVID-19 vaccination effort will create unprecedented challenges for targeting essential workers and vulnerable groups in the adult population, therefore, this component will support the correct identification and targeting of prioritized population groups for Stages 1 and 2 of vaccine deployment; (ii) training front-line delivery workers and ensuring reach and effectiveness of service delivery modalities (this may involve the temporary recruitment of health workers to be deployed in the acute phase); (iii) support the implementation and expansion of the ReDIV system to allow for the pre-registration and monitoring the vaccination of second stage of Phase 1 and later on Phase 2 of the COVID-19 vaccination roll out – the ReDIV system will allow to monitor the access of the population to vaccines and ensure that both men and women have equal access to vaccines and, in instances where a disproportionate sex coverage is found, take appropriate actions; (iv) strengthen and adapt Pharmacovigilance System (PVS) to be sensitive to detect AEFI for the COVID-19 vaccine using the Integrated Disease Surveillance and response system that includes the notification and investigation of serious adverse events and financing the development of specific guidelines and provision of necessary trainings; and (iv) ensure adequate waste management, through the investment in waste management and disposal supplies and maintenance, structuring the collection and transportation of waste to identified disposal sites and, implement waste collection, transport, and disposal plans. Jun 28, 2021 Page 18 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Component 3: Community engagement and risk communication for demand creation (US$3 million) 23. Community trust and vaccine confidence and preventing elite capture are crucial to vaccine acceptability and to improve participation in the COVID-19 response. Under this component, a national risk- communication plan, and activities to ensure community participation in COVID-19 vaccination efforts and accountability mechanisms will be ensured. This will include accurate information sharing, efforts to create demand, counter measures for addressing mis- or disinformation, and dissemination of educational materials to promote behavior changes that prevent transmission and COVID-19 infection, and climate induced water and vector-borne diseases (e.g., vaccination, hand washing, etc.). This Project will capitalize on previous undertakings by the Government of Angola, use existing structures such as the network of community health workers (community development and sanitary agents- ADECOS) as the community health agents channel recognized by the MOH to support the COVID-19 communications campaign, NGOs and their relations with established women and youth-led civil society organizations as well as with local and traditional leaders. There is an extensive experience of the use of the ADECOS networks in support of the health system actions and their engagement under World Bank health projects to support the yellow fever vaccination campaign, malaria outreach efforts, and nutrition interventions. 24. Building on global lessons, the project will support the use of digital technologies to increase demand, reduce vaccine hesitancy, and engage communities in the monitoring of the vaccine roll out. The project will support the incorporation of key messages and two-way information channels on COVID-19 vaccinations through interactive multi-media platforms (which can also be employed for vaccinations for other diseases including those induced by climate emergencies). These include online media surveillance including social media monitoring; and a 111 hotline to report adverse reactions and seek medical advice and referrals. The project will also support facility level outreach and accountability mechanisms (Co-Management Committees, Health Committees) at provincial and municipal levels to help monitor and promote the vaccine rollout, including to identify any cases of elite capture, corruption, or illicit fees for services. This will require the development of standard protocols and an integrated data management platform to triage, channel, and respond to complaints registered in these mechanisms. 25. Multi-level health promotion interventions will be tailored to the specific needs of vulnerable and hard- to-reach groups. These interventions will be designed to be understood by all, including women, girls, and other disadvantaged populations who are illiterate or lack access to information sources. Building “vaccine literacy� for the COVID-19 vaccine is also an opportunity to boost overall confidence in vaccinations, thereby leading to greater utilization and retention in the EPI program. To monitor perceptions and behavioral change interventions, financing will include beneficiary research on perceptions, obstacles, and levels of vaccine uptake and equity of distribution. 26. This project will also seek to address gender dimensions of social and behavior change communications, to ensure that beneficiary research identifies and monitors possible misconceptions that may be disproportionately held among women who face greater barriers in accessing reliable information, and among Jun 28, 2021 Page 19 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) men who may oppose vaccination for themselves or for female members of their households. Since the inception of the vaccine roll-out, the coverage among men has been significantly higher than women (likely due to decreased access as the targeted population stage 1 of phase 1 are mainly men) and therefore interventions to support gender sensitive risk communications should be delivered using multiple outreach mediums, 27. including messaging through radio, television, and community-based platforms in local languages. Risk communications will also incorporate information related to disease prevention in the event of climate shocks. Component 4: Project Implementation and Monitoring (US$ 7 million) 28. Institutional Strengthening. Building on the technical assistance provided through COVAX and other partners, the project will strengthen capacities of key institutions in Angola’s immunization system, including for planning, budgeting, and procurement; vaccine distribution, quality control and monitoring and related safeguards; and regulation of vaccine safety and indemnification systems, as well as developing contingency plans for safe vaccine delivery and availability in the case of climate emergencies. 29. This component will strengthen the existing Functional Governance and COVID-19 immunization implementation structure at the National Directorate of Public Health (DNSP in its Portuguese acronym), which will be the key technical agency for project implementation. Such strengthening will include the hiring of logisticians to support the roll out of the COVID-19 vaccine in all 18 provinces as well as risk communication and community engagement specialists to ensure a comprehensive demand creation and high levels of vaccine adherence and documentation of lessons learned from communications campaigns used across other countries to address the issue of vaccine hesitancy at the municipal level. The Program Implementation Unit (PIU) of the World Bank portfolio, known as the Unidade Central de Coordenação (UCC in its Portuguese acronym) will be responsible for project management and fiduciary aspects of project implementation (financial management, procurement, safeguards), and will be strengthened through this component in terms of the recruitment of additional staff and covering operating costs, necessary training and equipment, support for procurement, financial management, environmental and social risk and impact management, and monitoring and evaluation (M&E) and reporting activities. Emphasis will be placed on enhancing the monitoring and prospective evaluation framework for vaccine deployment at the country and subnational levels, to align with epidemiological shifts. Project and national M&E systems will be further strengthened with timely recording and reporting of performance benchmarks and results. The activities for M&E capacity building include: (i) collection of data from line ministries and other implementation agencies; (ii) compilation of data into progress reports; (iii) carrying out of surveys; (iv) carrying out of annual expenditure reviews; (v) impact evaluation on quantitative and qualitative aspects of the project interventions, and (vi) potentially contracting a -party monitoring agent. Climate activities financed by the project, such as training of health workers for handling climate-related disease outbreaks, refurbishment of health facilities to include solar panels, and vaccinator training on strategies to adapt vaccination efforts in the event of climate shocks, will also be monitored. Table 5: Project cost and financing (US$ millions) Jun 28, 2021 Page 20 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) Project Components IBRD Financing Trust Funds Total Component 1: Emergency COVID19 10 0 10 Response Component 2: COVID-19 Immunization 130 0 130 Component 3: Community engagement 3 0 3 and risk communication for demand creation Component 4: Project Implementation and 7 0 7 Monitoring . Total Costs 150 0 150 . Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Assessment of Environmental and Social Risks and Impacts . The proposed project has a national geographical scope and aims at supporting Governments efforts to implement the National Distribution and Vaccination Plan against COVID-19 vaccines and strengthening of immunization capacity. At this stage, details such as the size/capacity, footprint, and associated facilities of the project are not yet known. This information will be available at appraisal stage. The main source of risks and impacts are expected from the acquisition, deployment, and disposal of COVID-19 vaccines and consumables. The activities above have the potential to bring about environmental risks and impacts regarding: (a) medical and pharmaceutical waste management issues related to waste handling and collection, transportation, deployment, and disposal of hazardous and infectious healthcare and laboratory waste; (b) occupational health and safety issues (infections from COVID-19 and deployment and administration of vaccines); (c) soil and water contamination from mismanagement of health and pharmaceutical waste; and (d) community health and safety due to increased risk of exposure and contact with COVID-19 virus during vaccination campaigns or at healthcare facilities. Issues related to a broad risk of inequality in access to vaccines, due to political pressures to provide vaccines to groups that are not prioritized due to need or vulnerability or should target groups be misaligned with available vaccines are also expected to arise. A project implementation unit (PIU), referred to as the Unidade Central de Coordenação (UCC), leads the implementation of World Bank financed health sector investments in Angola. The UCC was formally established as a unit linked to the Ministry of Health (MOH). The capacity of the PIU to manage waste disposal is weak and the project will provide support to standard operating procedures and guidelines for the collection and disposal of waste appropriate to local conditions in line with Good International Industry Practices (GIIP). Jun 28, 2021 Page 21 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) E. Implementation Institutional and Implementation Arrangements 30. The MoH will be the primary implementing agency for this project. The Intersectoral Commission for Prevention and Control of COVID-19 led by the Minister of Health has been the Coordination Authority responsible for coordinating the implementation of the COVID-19 emergency activities. Within the Commission, the Functional Governance and COVID-19 immunization implementation structure at the DNSP will be responsible for the technical implementation of this project. The project implementation unit (the UCC) leads the implementation of World Bank financed health sector investments in Angola and will be responsible for project management and fiduciary functions for the project in coordination with key MOH departments and other stakeholders for implementation of project activities. The UCC is fully staffed4 and well-experienced in managing World Bank-financed projects. The UCC is led by an Operations Manager, to be recruited, and supported by technical, fiduciary, and administrative staff overseeing the operations related to the HSPSP, the Gavi Additional Financing, and the REDISSE IV regional project. The UCC managed the activation and implementation of the CERCs in coordination with the Ministry of Finance and will provide guidance to the MOH in the implementation of the Girls Empowerment and Education for All (P168699) project. The capacity at the DNSP and at the UCC will be bolstered through: (i) additional technical assistance for the EPI Program in the Directorate of Public Health; (ii) additional procurement specialists (including Hands-on Expanded Implementation Support, HEIS) as needed); (iii) a supply chain advisors and logisticians to strengthen the DNSP team in charge of the COVID-19 vaccine roll out; and (iv) other technical specialists as required in key MoH directorates and provincial-level health departments, including for public health and communications, the regulatory authority, the directorate of pharmaceuticals, and the National Reference Laboratory (INIS). Environmental and social safeguards specialists will also be engaged, in addition to technical assistance for strengthening and streamlining the Grievance Redress Mechanisms and improving waste management at provincial levels. As highlighted above the ReDIV system, managed by the COVID-19 immunization implementation structure at the DNSP/MOH, will provide the overall oversight and verification of the vaccination roll out and mitigate the risks of elite capture, forced vaccination and exclusion due to geographic dispersion. These implementation arrangements are being discussed with the counterpart and will be fully defined by negotiations (see figure below showing the organogram of PIU and the implementation arrangements for this project). Figure 7. Organogram of the PIU and implementation arrangements for the Angola COVID-19 SPRP project 4 Recruitment for the position of Operations Manager, currently vacant, is being conducted. Jun 28, 2021 Page 22 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) 31. The financial management (FM) and disbursement arrangements in place for the Angola HSPSP will apply to the proposed operation. The UCC will have overall fiduciary responsibility for implementation of this proposed project. An FM team consisting of two financial management specialists and four accountants, report to the UCC Operations Manager and have overall responsibility for project FM matters. The project funds, expenditures, and resources will be accounted for using a computerized accounting software and the basis of accounting will be Financial Reporting under Cash Basis. The PIU/MOH will prepare quarterly unaudited interim financial reports (IFRs) and provide such reports to the World Bank within 45 days of the end of each calendar quarter. The project financial statements (covering all project funds and expenditures) will be audited annually, and the audit report will be submitted to the World Bank no later than six months after the end of each financial year, that is June 30th of each following year. 32. The procurement arrangements for the project will be managed by the UCC team. The UCC includes a procurement officer and supporting procurement staff. The team that will support this operation is the same responsible for the procurement function under the current active health projects (HSPSP, REDISSE, GAVI). The UCC procurement team is made of a procurement officer and an assistant. The Procurement Specialist is being recruited. Considering the emergency response required for this Project and the overall risks involved, the UCC shall identify the procurement staff to be exclusively dedicated to this project. It should be composed at the minimum of a Procurement Specialist and a Procurement Assistant. The UCC team is staffed to manage environmental and social safeguards measures under the project. The UCC is fully staffed and well-experienced in managing World Bank-financed projects including one Jun 28, 2021 Page 23 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) operation under the Environmental and Social Framework (ESF) which is the REDISSE project (P167817), The UCC is led by an Operations Manager and supported by technical, fiduciary, and administrative staff overseeing the operations related to the HSPSP, the Gavi Additional Financing, and the (REDISSE) IV. The UCC is gradually developing strategies, structures, and environmental and social (E&S) risk management tools both at central and municipality levels to comply with ESF requirements and applicable national environmental regulations. The UCC has a team of E&S specialists which includes an overall safeguards coordinator and specialists focused on supporting the implementation of actions at the local level (provincial, municipal). As indicated above, the project implementation arrangements will be defined by negotiations. . CONTACT POINT World Bank Carmen Carpio Senior Health Specialist Borrower/Client/Recipient Angola Ministry of Finance Vera Daves Minister of Finance gci.minfin@minfin.gov.ao Implementing Agencies Angola Ministry of Health Silvia Lutucuta Minister of Health cdcvtalatona@gmail.com FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Jun 28, 2021 Page 24 of 25 Official Use The World Bank Angola COVID-19 Strategic Preparedness And Response Project (P176630) APPROVAL Task Team Leader(s): Carmen Carpio Approved By Practice Manager/Manager: Country Director: Issa Diaw 29-Jun-2021 Jun 28, 2021 Page 25 of 25 Official Use