Updated to Accommodate Contingency Emergency Action Plans of Ebola Virus Disease in November 2019 and COVID-19 in March 2020

MINISTRY OF HEALTH

Environmental and Social Management Framework

for

UGANDA REPRODUCTIVE MATERNAL, CHILD AND ADOLESCENT HEALTH SERVICES IMPROVEMENT PROJECT

(URMCHIP)

Draft Report Updated to accommodate Contingency Emergency Action Plans of Ebola Virus Disease in November 2019 and COVID-19 in March 2020

Updated by:

Eng.Dr. Lammeck Kajubi Queensland & Leeds LLC 23 Kabalega Crescent, Luzira, Kampala P. O. Box 22428, Kampala, UGANDA. T: 041-4268466, Mob: 078-2580480 E: [email protected]

March 2020

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Acronyms

BDR Births and Deaths Registration HIV Human Immunodeficiency Virus CAS Country Assistance Strategy HMIS Health Management Information System CERC Contingency Emergency Response Component COVID-19 Corona-virus disease 2019 caused by the 2019 novel coronavirus (SARS-CoV- 2) spreading rapidly across the world since December 2019, from Wuhan, Hubei Province, China CHEW Community Health Extension Workers HNP Health Nutrition and Population CRVS Civil Registration and Vital Statistics HPAC Health Policy Advisory Committee

DHT District Health Team HRH Human Resources for Health DLI Disbursement Linked Indicators HRHMIS Human Resources for Health Management Information System DRC Democratic Republic of Congo HSDP Health Sector Development Plan EEP Eligible Expenditure Programs EMP Environmental Management Plan ICD International Classification of Diseases EDHMT Expanded District Health Management ICT Information, Communication, and Technology Team eMTCT Elimination of Mother-to-Child- IPD In-Patient Department Transmission of HIV ESMF Environmental and Social Management Framework ETC Ebola Treatment Center MoH Ministry of Health EVD Ebola Virus Disease NIRA National Identification and Registration Authority GBV Gender Based Violence NECOC National Emergency Coordination and Operations Centre ESIA Environmental and Social Impact OPM Office of Prime Minister Assessment GDP Gross Domestic Product PHC Primary Healthcare GOU Government of Uganda SEA Sexual Exploitation and Abuse HCIV Health Center Type Four UPDF Uganda Peoples Defense Forces HCW Healthcare Waste URMCHIP Uganda Reproductive, Maternal, Neonatal and Child Health Improvement Project HCWM Health Care Waste Management IDA International Development Association VHT Village Health Teams IMR Infant Mortality Rate WB World Bank IPT Intermittent Preventive Treatment WHO World Health Organization

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Contents

ACRONYMS ...... III EXECUTIVE SUMMARY ...... IX 1 BACKGROUND...... 1

1.1 PROJECT DEVELOPMENT OBJECTIVE ...... 2 1.2 PROJECT BENEFICIARIES...... 2 1.3 SAFEGUARDS ASPECTS OF CERC ...... 2 1.4 PURPOSE OF UPDATING EARLIER ESMF TO INCORPORATE CERC ...... 3 2 PROJECT DESCRIPTION ...... 5

2.1 PROJECT COMPONENTS ...... 5 2.1.1 Component 1: Results-Based Financing for Primary Health Care Services ...... 5 2.1.2 Component 2: Strengthen Health Systems to Deliver URMCHIP Services ...... 6 2.1.3 Component 3: Strengthen Capacity to Scale-up Delivery of Births and Deaths Registration Services ...... 7 2.1.4 Component 4: Enhance Institutional Capacity to Manage Project Supported Activities ...... 7 2.1.5 Component 5: Contingency Emergency Response Component (CERC) for Ebola and COVID-19 Response...... 8 2.1.5.1 Surveillance, active case finding, contact tracing and investigation of cases ...... 13 2.1.5.2 Case management ...... 13 2.1.5.3 Infection prevention and control in health facilities and communities ...... 14 2.1.5.4 Risk communication, social mobilization and community engagement ...... 14 2.1.5.5 Psychosocial care ...... 15 2.1.5.6 Operational and programme support ...... 15 2.1.5.7 Strengthening the capacity of health staff to respond to EVD outbreaks ...... 15 2.1.5.7 Contingency Emergency Response Component (CERC) for COVID-19 ...... 15 2.2 PROJECT FINANCING ...... 17 2.3 ANTICIPATED SOCIAL AND ENVIRONMENTAL IMPACTS ...... 17 3 BASELINE BIOPHYSICAL AND SOCIO-ECONOMIC ENVIRONMENT ...... 20

3.1 LOCATION...... 20 3.2 CLIMATE ...... 20 3.3 PEOPLE AND CULTURES ...... 22 3.3.1 The People ...... 22 3.3.2 Population Dynamics ...... 22 3.4 NATURAL RESOURCES ...... 25 3.4.1 Atmospheric Resources ...... 25 3.4.2 Land as a Terrestrial Resources and its relation to the project ...... 25 3.4.3 Energy as a Cross-Sectoral Resources ...... 25 3.5 SOCIO-ECONOMIC AND CULTURAL ENVIRONMENT ...... 25 3.5.1 Human settlements, housing and urbanizations ...... 25 3.5.2 Safe water and sanitation...... 26 3.5.3 Environmental pollution ...... 26 3.5.4 Poverty ...... 26 3.5.5 General Health Statistics ...... 27 3.5.6 State of EVD Preparedness in Uganda ...... 27 3.5.6 State of COVID-19 Preparedness in Uganda ...... 28 4 PREPARATION AND OBJECTIVES OF THE ESMF ...... 30

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4.1 OBJECTIVE OF THIS ESMF ...... 30 4.2 METHODOLOGY USED TO PREPARE AND /OR UPDATE THE ESMF ...... 30 5 POLICY, LEGAL AND INSTITUTIONAL FRAMEWORK ...... 32

5.1 POLICY FRAMEWORK ...... 32 5.1.1 The National Environment Management Policy, 1994 ...... 32 5.1.2 The National Health Policy, 1999 ...... 32 5.1.3 The National Medical Equipment Policy, 2009 ...... 32 5.1.4 National Health Care Waste Management Plan (2009/2010–2011/2012) ...... 32 5.1.5 National Technical Guidelines for Integrated Disease Surveillance and Response, 2012 ...... 33 5.2 LEGAL FRAMEWORK ...... 33 5.2.1 Constitution of the Republic of Uganda, 1995 ...... 33 5.2.2 National Environment Act, Cap 153 ...... 33 5.2.3 Land Act, Cap 227 ...... 34 5.2.4 Local Governments Act, Cap 243 ...... 34 5.2.5 Public Health Act, Cap 281 ...... 34 5.2.6 National Environment (Standards for Discharge of Effluent into Water or on Land) Regulations, 1999 ...... 34 5.2.7 National Environment (Waste Management) Regulations, 1999 ...... 35 5.2.10 Employment Act, 2006 ...... 35 5.2.12 Occupational Safety and Health Act (2006) ...... 35 5.3 INSTITUTIONAL FRAMEWORK ...... 35 5.3.1 National Environment Management Authority (NEMA) ...... 35 5.3.2 Ministry of Health (MoH) ...... 36 5.3.3 Ministry of Gender, Labor & Social Development ...... 36 5.3.4 District Local Administration Structures ...... 36 6 THE WORLD BANK‟S SAFEGUARD POLICIES ...... 36

6.1 OPERATIONAL POLICIES ...... 36 6.2 WORLD BANK GROUP GUIDELINES ...... 38 6.2.1 WBG EHS Guidelines: “Air emissions and ambient air quality” ...... 39 6.2.2 WBG EHS Guidelines: “Waste management” ...... 40 6.2.3 WBG EHS Guidelines: “Healthcare facilities” ...... 40 6.2.4 WBG EHS Guidelines: “Hazardous materials management” ...... 43 6.2.5 WBG EHS Guidelines: “Construction and decommissioning” ...... 43 7 GENERIC ENVIRONMENTAL AND SOCIAL IMPACTS ...... 45

7.1 INTRODUCTION ...... 45 7.2 GENERIC CONSTRUCTION-PHASE IMPACTS ...... 45 7.2.1 Positive social impacts ...... 45 7.2.1.1 Income to material/ equipment suppliers and contractors ...... 45 7.2.2 Negative social impacts ...... 46 7.2.2.1 Occupational health safety (OHS) Risks for Contractors ...... 46 7.2.2.2 Injury to patients or healthcare staff by construction activities ...... 47 7.2.2.3 Traffic accidents ...... 48 7.2.2.4 Temporary disruption of healthcare services ...... 49 7.2.2.5 Social misdemeanor by construction workers ...... 50 7.2.2.7 Social impact of material transport ...... 52 7.2.2.8 Temporary scenic blight ...... 53 7.2.2.9 Improper site drainage creating breeding grounds for disease vectors ...... 54

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7.2.3 Negative environmental impacts ...... 54 7.2.3.1 Indoor air quality deterioration due to dust ...... 54 7.2.3.2 Improper management of construction activities/ works ...... 55 7.3 OPERATION PHASE IMPACTS ...... 56 7.3.1 Positives social impacts ...... 56 7.3.1.1 Improved medical services at healthcare facilities ...... 56 7.3.1.2 Employment opportunities ...... 58 7.3.1.3 Reduced public risks due to improvement in healthcare waste management ...... 58 7.3.1.4 Improved aesthetics and life of healthcare facilities ...... 58 7.3.2 Negative social impacts ...... 58 7.3.2.1 Community health risk due to improper waste management ...... 58 7.3.2.2 Occupational health and safety risks ...... 59 7.3.2.3 Fire risk ...... 61 7.3.2.4 Misuse or inability to use installed healthcare systems and equipment ...... 62 7.3.2.5 Lack of sustainability ...... 62 7.3.3 Negative environmental impacts ...... 62 7.3.3.1 Air pollution from onsite medical waste incinerators ...... 62 7.3.3.2 Improper medical waste management ...... 63 7.4 SOCIAL AND ENVIRONMENTAL IMPACTS OF EBOLA AND COVID-19 EMERGENCY OPERATIONS ...... 64 7.4.1.1 Inadequate risk communication and community engagement ...... 65 7.4.1.2 Impact of laboratory diagnostic capabilities in affected areas ...... 66 7.4.1.3 Improper clinical care, isolation of suspected cases and follow-up of survivors ...... 67 7.4.1.4 Weak EVD infection prevention and control measures (IPC + WASH)...... 68 7.4.1.5 Weak psychosocial support ...... 69 7.4.1.6 Safe and dignified burials (SDB) ...... 70 7.4.1.7 Inadequate logistics or their inefficient management ...... 71 8 ENVIRONMENTAL AND SOCIAL SCREENING PROCESS ...... 73

8.1 THE ENVIRONMENTAL AND SOCIAL SCREENING PROCESS ...... 73 8.2 THE SCREENING STEPS ...... 73 9 PROJECT IMPLEMENTATION ARRANGEMENTS ...... 77

9.1 INSTITUTIONAL AND IMPLEMENTATION ARRANGEMENTS ...... 77 9.2 SUSTAINABILITY ...... 78 9.3 MONITORING SOCIO-ENVIRONMENTAL ASPECTS COMPRISED IN THIS ESMF ...... 78 9.4 RESULTS MONITORING AND EVALUATION ...... 79 9.5 CAPACITY ENHANCEMENT NEEDS ...... 79 10 KEY FINDINGS FROM STAKEHOLDER CONSULTATION ...... 80

10.1 FINDINGS FROM IK INDIGENOUS PEOPLE ...... 80 10.2 FINDINGS FROM BATWA INDIGENOUS PEOPLE ...... 80 10.3 GENERAL VIEWS FROM OTHER STAKEHOLDERS CONSULTED ...... 80 10.4 HEALTH CENTRES ...... 81 10.5 VILLAGE HEALTH TEAMS (VHTS) ...... 81 10.6 RECOMMENDATIONS MADE BY STAKEHOLDERS ...... 81 11 ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP) ...... 82 12 EBOLA AND COVID-19 SURVEILLANCE CHANNELS IN UGANDA ...... 83 12 PROTOCOL TO MANAGE CHANCE FINDS ...... 84

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13 GRIEVANCE MANAGEMENT ...... 85

13.1 MANAGING GRIEVANCES ...... 85 13.2 COMPOSITION OF GRIEVANCE COMMITTEE FOR COVID-19 AND EVD-CERC ...... 86 14 HEALTHCARE WASTE MANAGEMENT GUIDELINES ...... 87

14.1 OVERVIEW OF PREVAILING CONDITIONS ...... 87 14.2 PRACTICAL GUIDELINES FOR MANAGEMENT OF EACH CLASS OF HEALTHCARE WASTE ...... 89 14.3 LINKAGE WITH HCWMP AND STRENGTHENING INFECTION CONTROL AT HEALTHCARE FACILITIES ...... 91 14.4 GENERAL HCWM INTERVENTIONS ...... 92 14.4.1 Existing situation ...... 92 14.4.2 Criteria on HCWM for selecting participating healthcare facilities ...... 92 14.4.3 Interventions planned by the project ...... 92 14.5 EVD & COVID-19 MEDICAL WASTE GUIDELINES ...... 92 14.6 EMERGENCY PREPAREDNESS AND RESPONSE ...... 94 14.7 MONITORING AND REPORTING ...... 95 15 ESMF IMPLEMENTATION BUDGET ...... 96 16 CONCLUSION ...... 97 BIBLIOGRAPHIES ...... 98 ANNEXES ...... 100

ANNEX 1: SCREENING FORM FOR POTENTIAL ENVIRONMENTAL & SOCIAL SAFEGUARDS (ESSF) ...... 100 ANNEX 2: ENVIRONMENT AND SOCIAL MITIGATION MEASURES CHECKLIST ...... 103 ANNEX 3: SAMPLE TERMS OF REFERENCE FOR EIA ...... 104 ANNEX 4: CLAUSES FOR CONSTRUCTION WORK CONTRACTS ON ENVIRONMENTAL COMPLIANCE ...... 106 ANNEX 5: RECORD OF CONSULTATION ...... 113 ANNEX 6: ESMP TEMPLATE ...... 148 ANNEX 7: INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) TEMPLATE...... 156 ANNEX 8: INFECTION AND PREVENTION CONTROL PROTOCOL ...... 161 ANNEX 9: FORMAT OF AN ENVIRONMENTAL REPORT ...... 163 ANNEX 10: HEALTHCARE WASTE MANAGEMENT GUIDELINES ...... 164 ANNEX 11: HEALTH CARE WASTE MANAGEMENT PLAN CHECKLIST ...... 167 ANNEX 12: CODE OF PRACTICE FOR CONSTRUCTION WORKERS ...... 170 ANNEX 13: OVERVIEW OF CERC ...... 175 ANNEX 14: WHO GUIDE FOR MANAGING EVD MEDICAL WASTE ...... 177 ANNEX 15: WHO GUIDANCE ON WASH ASSOCIATED WITH EVD ...... 181 ANNEX 16: COVID-19 EMERGENCY ACTIVITIES TO BE UNDERTAKEN...... 186 ANNEX 17: PERSONAL AND PUBLIC MEASURES TO CONTROL COVID-19 IN UGANDA ...... 195 ANNEX 18: GUIDANCE ON GBV CASE MANAGEMENT AND THE COVID-19 PANDEMIC ...... 197 ANNEX 19: TECHNICAL NOTE ON USE OF MILITARY FORCES TO ASSIST IN COVID-19 OPERATIONS ...... 208

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List of Tables

TABLE 2: EBOLA RISK-PRONE DISTRICTS IN UGANDA ...... 8 TABLE 3: DESCRIPTION OF CERC ...... 10 TABLE 4: CERC BUDGET FOR EVD ...... 11 TABLE 5: PLANNING SCENARIOS FOR COVID-19 CONTROL IN UGANDA ...... 16 TABLE 6: FUNDING REQUIRED FOR SCENARIO 3 COVID-19 RESPONSE PLAN OVER A YEAR...... 17 TABLE 7: WORLD BANK ENVIRONMENTAL AND SOCIAL SAFEGUARDS SHOWING ONES TO BE TRIGGERED ...... 37 TABLE 8: AIR EMISSION LEVELS FOR HOSPITAL WASTE INCINERATION FACILITIES (WBG GUIDELINES) ...... 42 TABLE 9: PERSONAL PROTECTIVE EQUIPMENT ACCORDING TO HAZARD ...... 46 TABLE 10: SOCIAL BENEFITS OF EACH PROJECT COMPONENT ...... 56 TABLE 11: ACCEPTABLE EFFECTIVE DOSE LIMITS FOR WORKPLACE RADIOLOGICAL HAZARDS ...... 61 TABLE 12: COMPONENTS OF ESMP ...... 82 TABLE 13: HEALTH FACILITY/HEALTH POST (RURAL) ...... 90 TABLE 14: HEALTH FACILITY/HEALTH POST (URBAN) ...... 90 TABLE 15: BUDGET ESTIMATE FOR IMPLEMENTING THE ESMF ...... 96

List of Figures

FIGURE 1: DISTRICTS WITH EBOLA VIRUS DISEASES (EVD) RISK IN UGANDA ...... 9 FIGURE 2: REGIONS IN UGANDA ...... 20 FIGURE 3: UGANDA RAINFALL MAP ...... 21 FIGURE 4: POPULATION PROJECTIONS FOR UGANDA (FOR HIGH AND LOW FERTILITY RATES) ...... 23 FIGURE 5: POPULATION DISTRIBUTION IN UGANDA ...... 24 FIGURE 6: SOME MEASURES USED BY THE PUBLIC TO CONTROL COVID-19 IN UGANDA ...... 29

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EXECUTIVE SUMMARY

Government of Uganda (GoU) obtained financing from the World Bank (The Bank) for the Uganda Reproductive, Maternal, Neonatal and Child Health Improvement Project (URMCHIP Project). The project is supporting the national efforts to scale up delivery of essential URMCHIP services described in the URMCHIP Sharpened Plan. The project is supporting Uganda‟s Ministry of Health (MoH) to address critical health systems bottlenecks constraining URMCHIP service delivery, including strengthening supervisory functions and improving the quality of care. In addition, the project is supporting efforts to strengthen institutional capacity for Civil Registration and Vital Statistics (CRVS) to scale up provision and utilization of Birth and Death Registration (BDR) services. The project targets districts with high URMCHIP disease burden and low URMCHIP service coverage and utilization and is being implemented in close collaboration and coordination with other URMCHIP programs to ensure alignment of the programs to the URMCHIP Sharpened Plan. . The project has five components listed below and described in detail in Chapter 2, including the Contingent Emergency Response Component to Ebola Virus Disease (EVD) and COVID-19 outbreak: a) Component 1: Results-Based Financing for Primary Health Care Services b) Component 2: Strengthen Health Systems to Deliver URMCHIP Services c) Component 3: Strengthen Capacity to Scale-up Delivery of Births and Deaths Registration Services d) Component 4: Enhance Institutional Capacity to Manage Project Supported Activities e) Component 5: Contingency Emergency Response Component (CERC) for Ebola and COVID-19 response

Component 1 supports implementation of RBF activities in a phased manner to ultimately cover 60 districts in Uganda. Activities for Components 2 and 3 are mainly national-level activities, and will accord priority to low capacity and remote districts. The interventions under the project involve improvement in provision of health services to communities, including those that are vulnerable. The project will contribute to improved health services and the treatment of more people and consequently there will be increased generation of medical waste in the health facilities, and the need for appropriate controls to minimize the associated risk of spread of disease. Component 2 will involve small scale repairs, renovations, and construction of maternity wards and appropriate environmental and social controls will be needed in respect to any land acquisition and construction activity. The environmental and social impacts that could arise from the project have been predicted. On 17th July 2019, World Health Organization (WHO) declared the EVD outbreak in DRC a Public Health Event of International Concern (PHEIC) after confirmation of an EVD case in Goma because; it had crossed borders (Uganda) and spread into a major business city (Goma) increasing the risk of spread of Ebola to other countries and other regions. With the declaration of PHEIC, it is expected that Uganda should enhance its preparedness efforts to counter any major spill overs and strengthen its preparedness efforts in the high-risk districts. This risk of EVD outbreak is exuberated by presence of porous borders, high population movements between the countries along the border lines (over 400,000 at the Mpondwe Border alone per month), presence of Markets and high trade across the borders, intercultural and homogeneity of the communities across both borders. These scenarios are critical in increasing the risk of importation of EVD from the affected areas in DRC into Uganda. Therefore, there is a need to sustain the gains made so far to heighten and strengthen surveillance for early identification and appropriate/timely response to any EVD threat, if identified.

In order to comply with GoU and WB‟s environmental requirements and to aid various stakeholders to identify and effectively manage potential environmental and social impacts of the proposed project, this Environmental and Social Management Framework (ESMF) which was first prepared and disclosed in June 2016, along with a Resettlement Policy Framework (RPF), an Indigenous Peoples Policy Framework (IPPF) and Indigenous Peoples Plan (IPP), has been updated to incorporate CERC – EVD activities. This ESMF outlines the framework and mechanisms for environmental and social impact screening, determining extent of required environmental assessment and assessment of environmental and social impacts arising from proposed project implementation, and gives generic guidance on appropriate mitigation measures, and institutional arrangements

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for monitoring. This framework is needed since specific project locations under the proposed project are yet to be determined. Where necessary, site specific Environmental and Social Management Plans shall be prepared during project implementation. In terms of EVD outbreak response, a Contingency Emergency Plan has been prepared by Government of Uganda (Ministry of Health) and follows set Standard Operating Procedures (SOPs) recognized by World Health Organization.

With the outbreak of Corona Virus Disease (COVID-19), an ESMF earlier updated in November 2019 to provide for Ebola Virus Diseases (EVD) emergency preparedness in Uganda has been updated to enhance national capacity to handle COVID-19 outbreak. The World Health Organization (WHO) has declared the on-going outbreak of the Corona Virus Disease (COVID-19) as a pandemic.

COVID-19 was first detected in Wuhan in China in December 2019 and it is believed to have originated from wild animals, passing to humans through wildlife trade and wet markets. The disease has since spread globally claiming lives in many nations. As of 23 March 2020, about 349,179 cumulative cases and 15,297 deaths had been reported in over 167 countries and territories worldwide1.

COVID-19 is highly infectious and given the number of travellers coming to from affected countries, the risk of importation of COVID-19 into the country is considered very high by WHO. If not averted, COVID-19 can affect Uganda‟s economy in several ways, some of which are: by directly affecting production, by creating supply chain and market disruption, and by its financial impact on firms and markets. With disruption of several facts of life such as closure of schools, shopping malls/supermarkets, open markets, workplaces and banning public gatherings, the health, socio-economic and environmental impact of COVID-19 can never be underestimated.

It is therefore pertinent that Uganda develops a national preparedness and response plan to enable high alertness and operational readiness. The goal is to provide a framework for infection prevention and rapid control of COVID-19 by delaying importation, enabling containment, reducing of morbidity and mortality and mitigation of economic and social disruption resulting from COVID-19 outbreak. Response to COVID-19 emergency will be multi-sectoral involving Ministries, Departments, Agencies, Development Partners, private sector entities and other stakeholders. The emergency plan for COVID-19 will cover one year from March 2020 to April 2021 and therefore this will be the temporal scale of this updated ESMF.

Key stakeholders will be involved with implementation or monitoring this project are:

. Ministry of Health . District Environment Officers . District Health Officers . Health workers in the facilities . Members of Vulnerable and Marginalized Groups (Batwa) and their representatives at the respective areas/districts . Village Health Teams . NGOs working in health sector . Communities in Districts at risk of outbreak of EVD and COVID-19.

Capacity building will be essential for effective implementation of the ESMF. MoH will hire Environmental Health Specialist to undertake implementation of environmental aspects of the project as outlined in this ESMF. In order to ensure they are effective in monitoring not only construction activities but also associated operation phase socio- environmental impacts as provided in this ESMF, capacity enhancement is recommended for the Environmental Health Division of MoH, the District, staff in Health Centers and Village Health Teams in areas of:

1 Source: https://www.worldometers.info/coronavirus/ (Accessed 23 March 2020)

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a) EIA process in Uganda b) Environmental Health-impact relationship c) Impact assessment d) World Bank Safeguards e) Environmental monitoring f) Stakeholder engagement g) Grievance management h) Capacity building of local medical staff in health waste management i) EVD Management at different levels by the Health Workers and Communities. j) COVID-19 emergency management at national and local levels.

Also recommended as part of capacity building is training on:

. Occupational, Health and Safety (OHS) management; and, . Use of Military Forces in implementation of COVID-19 activities.

A technical guide on involvement of the military in COVID-19 operations has been added to ESMF as Annex 18.

Main generic impacts associated with the project are outlined in table ES 1 below:

Table ES1: Key potential impacts of each project phase Phase and sense of impacts Impacts 1 CONSTRUCTION-PHASE i) Positive social impacts Income to material/ equipment suppliers and contractors where COVID- 19 emergency operations entail procurement of local supplies

ii) Negative social impacts a) Occupational health safety (OHS) Risks for Contractors b) Injury to patients or healthcare staff by construction activities c) Traffic accidents d) Temporary disruption of healthcare services e) Social misdemeanour by construction workers f) Social impact of material transport g) Temporary scenic blight h) Non compensation of PAPs i) Social exclusion (based on gender and other vulnerabilities) iii) Negative environmental a) air quality deterioration due to dust impacts b) Improper management of construction waste and debris. c) Improper management of construction site and surrounding environment, e.g. loss of vegetation cover, poor sanitation practices.

2 OPERATION-PHASE i) Positives social impacts . Satisfactory containment of COVID-19 pandemic would avoid loss of life and potential grave socio-economic impact on Ugandan people.

Currently the country has lowered its economic growth projection for this financial year by 0.3% to 0.8% from the targeted 6 percent for financial year 2019/2020. Schools and many other facets of public

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Phase and sense of impacts Impacts life have been shut down. Therefore control of COVID-19 would avoid impoverishing millions of Ugandans2.

. Improved medical services at healthcare facilities . Employment opportunities . Reduced public risks due to improvement in healthcare waste management . Improved aesthetics and life of healthcare facilities . Effective response to and control of EVD outbreak . Improved hygiene practices due to mass and massive sensitisation – hand washing among others ii) Negative social impacts . Beside loss of life, uncontrolled spread of COVID-19 in Uganda would have significant socio-economic impact on the country. The biggest impact would be on the services sector. Travel restrictions are already affecting the tourism sector including hotels, accommodation and transportation. Border closures and supply chain disruptions are hampering trade. Closure of learning institutions, public places and places worship is disrupting social, cultural and religious life of people. . Community health risk due to improper waste management . Occupational health and safety risks . Fire risk . Misuse or inability to use installed healthcare equipment . Stigma for COVID-19 patients and their families in the communities

iii) Negative environmental . Improper management of waste from COVID-19 emergency impacts operations (e.g. onsite open-air combustion) pose adverse environmental impacts. . Air pollution from onsite medical waste incinerators . Improper medical waste management . Incautious management of medical waste contaminated with Ebola virus.

Mitigation measures for potential negative impacts have been discussed in Section 7. Clauses for construction work contracts on environmental compliance are provided in Annex 4 while Code of Practice for Construction Workers is outlined in Annex 12. Healthcare waste management procedure in line with national requirements, and training in the implementation of the procedure including Guidance on healthcare waste management in line with national requirements is provided in Annexe 8 and 9 provides a checklist for HCWM. It is estimated that budget for implementing this ESMF including costs of monitoring and capacity building is USD 1,640,000 throughout the 5 year project life as shown in table below. Management of related environmental and social aspects of EVD response is estimated to cost USD 250,000. This estimate is bound to fluctuate and vary based on the circumstances on-ground.

Table ES2: Budget estimate for implementing the ESMF Item Cost Estimate (US $) Notes 1 Mitigation action required during 400,000 Control of erosion, dust, drainage impacts Renovations/repairs/ construction of and construction waste management new health centers

2 https://www.finance.go.ug/press/statement-minister-finance-parliament-economic-impact-covid-19-uganda (Accessed: 23 March 2020)

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Item Cost Estimate (US $) Notes 2 Budget for position of Environmental 180,000 Budgeted at USD3000 gross monthly salary Health Specialist for 5 years 3 Improvement of HCW management 200,000 Lumpsum cost for entire project through support to implementation of the national health care waste plan (including training, preparation of the HF HCWM plans) 4 Supervision and monitoring by 200,000 Budget based on monitoring plan below: district officers (responsible for social and environment affairs) . 10 Districts sampled per monitoring quarter . USD 1000 per district per quarter as total expenses for all staff involved. . 20 Quarters in 5 years (hence total: 10 Districts x 20 Quarters x USD1000) 5 Training of health workers on HCWM 320,000 Training of Health Workers in proper HCWM and and strengthening infection control World Bank Safeguards (assuming an average of at health facilities USD80,000 per region) 6 Renovation of existing healthcare To be part of contractors‟ assessment and price waste facilities quote 7 Lumpsum support for purchase of 400,000 Cost for all four regions HCW containers 8 Social and environmental 250,000 For medical staff and community sensitization in sensitization and training for Ebola-prone districts and management of EVD communities and medical staff about related waste. Ebola control, and management of medical waste associated with EVD. 9 Social and environmental 250,000 For medical staff and community sensitization in sensitization and training for and management of COVID-19 related communities and medical staff about environmental and social impacts. Ebola and COVID-19 control, and management of medical waste associated with COVID-19. TOTAL (US$) 2,200,000

There little doubt that the entire country is at risk but to focus preparedness efforts, specific high risk areas have been identified as follows:

a) Kampala and Wakiso - due to connection with Entebbe International Airport, and a high number of travellers b) Cities and towns with high congregation of high-risk travellers especially in construction projects with camps. c) Selected border crossing points of entry with expected inflow of persons. d) Districts with a regional referral hospitals where the isolation facilities are and sentinel sites for Severe Acute Respiratory Illness (SARI) and Influenza Like Illness (ILI)

The scenarios have been described in Table ES2 below basing on possible risk and scale of outbreak.

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Table ES2: Risk scenarios Scenario Actions Scenario 1: Best case scenario Development of contingency plan, Enhanced surveillance and screening at No cases reported in Uganda. points of entry; Prepositioning of logistics at PoEs and regional referral hospitals; conduct risk communication and community engagement; IPC and WASH; District categorization and preparedness focused in high risk districts, build surge capacity and conduct simulation exercise (SIMEX).

Note: Considering that 23 COVID-19 cases have been confirmed in Uganda as of 28 March 2020, Scenario 1 does not hold any longer. Scenario 2: Most likely scenario Management of confirmed case(s); Enhanced surveillance; Risk Confirmed cases in one geographical communication and community sensitization and engagement; Infection location, enhanced preparedness Prevention and Control and WASH; Psychosocial support activities; District across the country categorization and preparedness focused in high risk districts and response in affected areas Scenario 3: Worst case scenario Cross pillar response at community level, points of entry escalate to Confirmed in multiple locations, or response capacities; Escalation of response activities to the NECOC under overwhelming numbers of cases OPM; Surge teams (including the UPDF and international medical teams)

Uganda will focus preparedness on Scenario 3. The focus will be establishing national capacity and capability to delay importation of COVID-19, detect and isolate cases early, and manage those that progress to severe and critical stages appropriately.

Table ES3 below shows budgetary requirements for COVID-19 emergency control plan.

Pillar Budget Mobilized resources Funding gap (US$) (US$) (US$) Coordination and leadership 317,241 103,691 213,550 Surveillance, laboratory support & POEs 861,734 574,883 286,851 Risk communication, social mobilization and 1,353,076 84,917 1,268,159 community engagement Case management, infection prevention and 3,517,649 335,747 28,704,635 control ICT and Innovation 51,933 32,113 19,820 Mental health and Psychosocial support 1,084,865 37,050 1,047,815 Logistics 37,531,913 432,949 11,576,231 Total 44,718,409 1,601,351 43,117,060

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1 BACKGROUND

Government of Uganda (GoU) has obtained financing from the World Bank (The Bank) for the Uganda Reproductive, Maternal, Neonatal and Child Health Improvement Project (URMCHIP). The project will assist Uganda‟s Ministry of Health (MoH) to address critical health systems bottlenecks constraining URMCHIP service delivery, including strengthening supervisory functions and improving the quality of care. In addition, the project will support efforts to strengthen institutional capacity for Civil Registration and Vital Statistics (CRVS) to scale up provision and utilization of Birth and Death Registration (BDR) services. The project targets districts with high URMCHIP disease burden and low URMCHIP service coverage and utilization and will be implemented in close collaboration and coordination with other URMCHIP programs to ensure alignment of the programs to the URMCHIP Sharpened Plan.

Through restructuring, URMCHIP will in addition support CERC Ebola response activities following GoU‟s request to World Bank to support the National Ebola Response Plan. In July 2019 World Health Organization (WHO) declared the EVD outbreak in DRC a Public Health Event of International Concern (PHEIC) and accordingly Component 5 (CERC-EVD) of URMCHIP has been introduced to provide rapid allocation of funds to support recovery measures in case of Ebola outbreak in Uganda. The CERC response to EVD outbreak has been activated to support recovery efforts, such as repair or restoration of basic physical assets, protection of critical development spending such as on health and education, creation of programs to jump‐start economic activity or the activation or scaling up of safety nets to mitigate impact on vulnerable groups (in this case the Batwa known to live in Ebola-prone districts).

COVID-19 is highly infectious and given the number of travellers coming to from affected countries, the risk of importation of COVID-19 into the country is considered very high by WHO. If not averted, COVID-19 can affect Uganda‟s economy in several ways, some of which are: by directly affecting production, by creating supply chain and market disruption, and by its financial impact on firms and markets. With disruption of several facts of life such as closure of schools, workplaces and banning public gatherings, the health, socio-economic and environmental impact of COVID-19 can never be underestimated.

It is therefore pertinent that Uganda develops a national preparedness and response plan to enable high alertness and operational readiness. The goal is to provide a framework for prevention and rapid control of COVID-19 by delaying importation, enabling containment, reducing of morbidity and mortality and mitigation of economic and social disruption resulting from COVID-19 outbreak. Response to COVID-19 emergency will be multi-sectoral involving Ministries, Departments, Agencies, Development Partners, private sector entities and other stakeholders.

Due to the fluidity of the outbreak situation emergency plan for COVID-19 will cover one year from March 2020 to April 2021 and therefore this will be the temporal scale of this updated ESMF.

3 Source: https://www.worldometers.info/coronavirus/ (Accessed 23 march 2020)

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1.1 Project Development Objective

The Project Development Objectives (PDOs) are to: (a) improve utilization of essential health services with a focus on reproductive, maternal, newborn, child and adolescent health services in target districts; and (b) scale up birth and death registration services.

1.2 Project Beneficiaries

The primary project beneficiaries are women of childbearing age, adolescents, and children under-five (including newborns and infants) from selected districts in the country with a high disease burden. The beneficiaries will benefit from a package of high impact quality and cost-effective URMCHIP interventions. In addition, communities will benefit from enhanced BDR services. Contingency Emergency Response Component (CERC) for Ebola response will benefit the entire nation but specifically the 26 risk-prone districts shown in Section 2.1.5. Measures to control spread of COVID-19 will benefit the entire population in Uganda.

1.3 Safeguards aspects of CERC a) Social safeguards

Originally approved safeguards instruments remain valid and up to date, as no changes to original project activities are envisioned. In particular, OP 4.10 (Indigenous Peoples) was triggered under the parent project and will remain triggered under the proposed operation. An Indigenous Peoples Framework (IPPF) was prepared under the parent project and disclosed as per World Bank guidelines. b) Environmental safeguards

Since this ESMF update only addresses the financing gap due to CERC activation, the scope and nature of the original project activities remain the same and there is no change in the Safeguard Policies triggered. The parent project was assigned Environmental Category B and while EVD/ COVID-19 is a high risk public health emergency, associated social and environmental concerns are manageable just like for any other diseases, hence project classification remains unchanged. The main environmental safeguards aspects of EVD outbreak management will largely be covered by OP 4.01 Environmental Assessment which requires screening of activities, identifying likely environmental and social impacts, development and implementation of management/mitigation plans; OP 4.11 Physical Cultural Resources arising from likely support of civil works which may entail excavations and possible chance finds, for which guidance (Chance Finds Procedure) is already provided in this ESMF; and Environmental Health and Safety Guidelines which will guide management of both Public and Occupational Health and Safety aspects of the COVID-19 activities. These shall be implemented alongside the National Guidelines for Infection Prevention and Control. The COVID CERC activities shall also take cognizance of OP 4.10 Indigenous Peoples in regard to Batwa indigenous peoples found in Bundibugyo, Kasese, Kisoro and Ntoroko and the “Ik” found in Karamoja region since COVID-19 is a nation-wide pandemic, and could affect indigenous groups. c) Technical and operational aspects of CERC

Specific to COVID-19, the objectives of the emergency action plan (EAP) is to provide a framework for prevention and control of COVID-19 by delaying importation, interrupting transmission early and fast, minimizing morbidity and mortality as well as mitigating economic and social disruption that may result from this outbreak. This objectives will be achieved through the following strategies:

i) development of country capacity for early detection, confirmation, reporting and referral of suspected cases to designated isolation units;

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ii) development of the capacity for case management including management of severe case; iii) raising of public awareness on the risk factors for transmission, prevention and control of COVID-19; iv) strengthening of infection prevention and control measures required to mitigate spread of COVID-19 in health facilities, institutions and at the community level; v) strengthening of capacities for coordination, data management and surge capacity; and vi) application of multi sectoral approach to minimize social and economic impact.

Activities funded under CERC will remain relevant for emergency response and include: detection of all suspected cases and collection of samples for laboratory confirmation; identification and tracking of all EVD and COVID-19 contacts; organization of medical and psychosocial case management including nutritional support; reducing the risk of transmission of EVD and COVID-19 in the community; strengthening infection prevention and control measures at health facilities; strengthening surveillance in health districts vulnerable to transmission of EVD and COVID-19 because of population movement; strengthening community mobilization through participatory communication on social, behavioral change, and local community engagement and participation; immunization of at‐risk groups (front‐line staff, case contacts, and contact of contacts); and free care to all infected health areas. All these activities are core interventions for a response to EVD and COVID-19 outbreak. No changes are envisioned with regard to implementation arrangements of CERC by the Ministry of Health (MOH). Implementation of CERC-IP will follow CERC operations manual and the Standard Operating Procedures (SOP) prepared to support EVD and COVID-19 preparedness and response activities. CERC Implementation Plan (CERC-IP) is a subset of the National Contingency Emergency Response Plan and will focus on the most urgent short-term response needs over the next 12 months which are not financed by other sources.

Stakeholder engagement and Information Disclosure: For the reason that successful execution of EVD and COVID-19 emergency operations hugely depends on effective communication among all stakeholders, risk communities and the country generally. Additionally, the six pillars of EVD and COVID-19 control below depend in effective communication and information disclosure:

. Coordination and leadership . Surveillance . Case management and treatment . Logistics management . Risk communication . Vaccination and treatment

1.4 Purpose of updating earlier ESMF to incorporate CERC

The objective of updating the earlier ESMF is to provide an Environmental and Social Management Framework (“ESMF”) relevant and adequate to support implementation of CERC-related actions in Uganda.

An ESMF is defined as:

An instrument that examines the issues and impacts associated when a project consists of a program and/or series of sub-projects, and the impacts cannot be determined until the program or sub-project details have been identified. The ESMF sets out the principles, rules, guidelines and procedures to assess the environmental and social impacts. It contains measures and plans to reduce, mitigate and/or offset adverse impacts and enhance positive impacts, provisions for estimating and budgeting the costs of such measures, and information on the agency or agencies responsible for addressing project impacts.

The updated COVID19 CERC ESMF therefore is prepared to assist Government of Uganda in developing environmental and social (E&S) instruments in response to COVID-19 situations following national regulations and

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the World Bank‟s Environmental and Social Safeguards Policies. This ESMF includes generic Environmental and Social Management Plan (ESMP) and Infection Control and Waste Management Plan (ICWMP). The former aims to provide an overarching action plan for the management of environmental, social, health and safety (ESHS) issues associated with the construction and operation of healthcare facilities in response to COVID-19. The latter focuses on proper infection control and healthcare waste management practices during operation of healthcare facilities. The ICWMP is considered part of the ESMP.

In particular, this updated ESMF has:

. Described COVID-19 scenarios and emergency activities and integrate them in existing ESMF, . Provided objectives of COVID-19 emergency activities, . Concisely discussed World Bank safeguards policies that are applicable to COVID-19, and reasons why other safeguards would not be triggered by COVID-19 emergency activities, . Updated legal and institutional framework to reflect association to COVID-19 emergency activities, . Discussed environmental and social context of proposed areas of COVID-19 emergency activities and document relevant baseline conditions thereof, . Provided safeguards screening and mitigation in the updated ESMF that is applicable to the COVID-19 plan; specifically identifying potential environment and social risks and mitigation and to develop procedures to address environment and social issues, . Analysed linkage of COVID-19 activities to Vulnerable and Marginalized Groups (Batwas and Iks) and designed specific measures targeting their specific cultural-social setup, . Designed an accessible grievance redress system applicable to COVID-19 plan, . Discussed implementation responsibilities for safeguards screening and mitigation, . Appraised capacity-building and monitoring necessary for implementation of the safeguards, and . Consultation with responsible task team at MoH.

Additionally, based on characteristics of COVID-19 emergency operations, the following information has been documented:

. Types of activities likely to be financed under COVID-19 plan (See Annex 16); . Potential emergencies and evaluation of risks and mitigation measures associated with above activities; . Likely vulnerable locations and groups and where needed some social assessment to guide emergency responses (e.g. what existing social conflicts could be exacerbated by an emergency situation or what perceptions require information dissemination to avoid conflict with COVID-19 Emergency Response Teams in affected communities?); . Appraisal of capacity and institutional arrangements for environmental and social due diligence and monitoring. This should identify necessary capacity-building measures, and guidance on emergency small- scale civil works; . Assessment of potential instruments (ESIAs, EMPs, etc.) that will need to be developed during implementation of emergency responses plan and emergency response actions that can proceed with no additional environmental or social assessment, . Resources that will be required for implementation of the updated ESMF . Templates of Environmental and Social Management Plan (ESMP) and Infection Control and waste Management Plan (ICWMP) for management of COVID-19 activities, elaborated under 3.1 above.

The following information is also provided as part of the annexes:

 Screening form for potential environment and social issues  ESMP template  ICWMP template  Infection and prevention control protocol

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2 PROJECT DESCRIPTION

This chapter outlines components of the proposed project and financing arrangements.

2.1 Project Components

The project comprises five components, namely:

. Component 1: Results-Based Financing for Primary Health Care Services . Component 2: Strengthen Health Systems to Deliver URMCHIP Services . Component 3: Strengthen Capacity to Scale-up Delivery of Births and Deaths Registration Services . Component 4: Enhance Institutional Capacity to Manage Project Supported Activities . Component 5: Contingency Emergency Response Component (CERC) for Ebola and COVID-19 response

The above components are described in sections below.

2.1.1 Component 1: Results-Based Financing for Primary Health Care Services

The objective of this component is to institutionalize and scale-up RBF with a focus on URMCHIP services. The RBF design for the project draws on the National RBF Framework, and aims at incentivizing selected District Health Teams (DHTs) and HC III and IV to expand provision of quality and cost-effective URMCHIP services. Under this, the health centres will support the VHTs in their catchment areas to promote community based URMCHIP services, including nutrition.4 The district selection was based on a predefined criteria, which included: district poverty levels, access/coverage of URMCHIP services, disease burden, and presence/absence of other RBF schemes.5 The selection of health facilities in the designated districts will be based on their readiness to provide URMCHIP services using a RBF readiness assessment tool adapted from the health facility quality of care program. To further strengthen the referral system, strategically located hospitals with capacity to provide ambulance and URMCHIP referral services will be selected based on criteria outlined in the Project Implementation Manual (PIM). As part of the RBF institutionalization, government will establish an RBF unit in the Health Planning Department to oversee RBF operations. The unit will also serve as the secretariat for the Interagency RBF Coordination Committee to promote coordination, alignment and harmonization of RBF programs. Implementing the various RBF programs together, within a common framework is expected to promote RBF sustainability.

The RBF package of high-impact interventions were selected from the URMCHIP Sharpened Plan. The URMCHIP package comprises interventions at health facilities and the community level, and includes: (a) ANC, (b) safe delivery; (iii) comprehensive emergency obstetric care; (iv) essential newborn and postnatal care services; (v) post-abortal care; (vi) family planning; and (vii) community-based URMCHIP services including nutrition, prevention and treatment of common childhood diseases and provision adolescent health services. HCs on the RBF scheme will be rewarded for performance based on key quantity and quality indicators using a fee-for-service provider payment mechanism embedded with a quality enhancing score. DHTs will be rewarded to supervise RBF facilities on key health systems governance indicators on a quarterly basis. The RBF payment framework will embrace an equity dimension to cater for districts in remote or hard-to-reach areas. The project will ensure that the services are provided equitably and in a way that all aspects of the community can use, irrespective of whether they are Indigenous Peoples, vulnerable/ marginalized groups, etc.

4 The government is considering adopting CHEWs. The project will support the CHEWs when the change takes effect. 5 Reproductive health voucher schemes are currently under implementation in 50 districts (26 under the Bank financed project (P144102) and 24 under the USAID-funded project. In addition, the BTC is implementing a supply-side RBF in 10 districts and CORDAID in the Busoga Region. These excludes small schemes by partners in the districts.

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The project under this component will finance: (a) selection process and training of RBF health providers; (b) performance-based payments to health facilities, hospitals and the DHTs based on verified results; (c) RBF supervision and capacity building; and (d) external verification/counter-verification.

2.1.2 Component 2: Strengthen Health Systems to Deliver URMCHIP Services

The objective of this component is to strengthen institutional capacity to deliver URMCHIP services. The project will support the MoH to implement priority health systems strengthening actions to enhance capacity to deliver URMCHIP services. The selected priority actions from the URMCHIP Sharpened Plan address the most critical health systems bottlenecks to URMCHIP service delivery, and include improving: (a) availability of essential drugs and supplies; (b) availability and management of the health workforce; (c) availability and functionality of medical equipment in health facilities; (d) health infrastructure for Primary Healthcare (PHC) services; (e) quality of care and supervision. The actions will be included in the annual plans and budgets of the MoH.

(a) Improved availability of essential drugs and supplies (US$10 million): The MoH will (i) procure and distribute essential URMCHIP commodities, including mama kits, manual vacuum aspiration kits, and contraceptives and (ii) upgrade the warehousing system in National Medical Stores (NMS). In order to strengthen district capacity to quantify drug needs, the MoH will support the districts to assign medicines management supervisors to the DHTs and complete the roll out the electronic logistics management system in the remaining districts. (b) Improved availability and management of the health workforce (US$5 million): The MoH will support districts to (i) recruit staff and fill vacancies within the available annual wage bill allocation in a timely manner; (ii) train URMCHIP cadres in short supply (midwives, anaesthetists and laboratory technicians); and (iii) support in-service training and mentorship programs targeting URMCHIP services.6 (c) Improved availability and functionality of medical equipment in health facilities (US$10 million): The project will support the MoH to: (i) procure and distribute critical URMCHIP equipment to selected facilities; (ii) redistribute basic medical equipment from districts/health facilities where they are not in use; and (iii) strengthen the inventory management system for equipment. (d) Improved health infrastructure for PHC health facilities (US$17 million): The project will support the MoH to: (i) construct maternity units in 40 HC IIIs (in non RBF districts) after establishing a clear justification and rationale and (ii) develop guidelines for RBF health facilities to perform simple renovation of health facilities to enhance their functionality. (e) Improved quality of care and supervision (US$10 million): The project will support the MoH to: (i) effectively supervise and support DHTs in a coordinated and systematic manner through the area supervision teams;7 (ii) roll out the HFQCAP; (iii) issue service standards/protocols including maternal and perinatal death audits, health care waste management (HCWM); and client charters; (iv) develop and issue guidelines to the districts to contract eligible hospitals to provide ambulance and referral services on a fee-for-service basis; (v) support DHTs to strengthen their community health outreach programs through properly trained, equipped, motivated and supervised VHTs; and (vi) strengthen citizen engagement through the Health Unit Management Committees (HUMCs), constituency task forces and client charters.8

6 Using Association of Gynecologists, Pediatricians, Private Midwives and RMNCAH community service organizations 7 Area Teams comprise central level staff and are responsible for the quarterly supervision of the districts. The Resource Centre is responsible for managing the HMIS. 8 These citizen engagement tools are already in use. The project will support expansion of their implementation.

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2.1.3 Component 3: Strengthen Capacity to Scale-up Delivery of Births and Deaths Registration Services

The objective of the component is to strengthen institutional capacity for CRVS and scale-up BDR services. The project will support government efforts to strengthen capacity of the principle CRVS institutions at central and subnational levels to carry out their mandate to provide BDR services and to scale-up BDR services countrywide.

Sub-component 3.1: Strengthen Institutional Capacity to Deliver BDR Services (US$2 million).

The key objective of the sub-component is to strengthen the principle CRVS institutions to carry out their mandates of BDR. The project will support NIRA at the national level to enhance its oversight and coordination function and its affiliate offices at subnational level (district and sub-county) to provide BDR services, giving priority to: . development and dissemination of a national CRVS policy, strategy and communication strategy; . development and training of staff on the BDR protocols and manuals; and . establishment and operationalization of a CRVS monitoring and evaluation (M&E) system, and use of CRVS data for planning and accountability purposes.

Sub-component 3.2: Scale-up Birth and Death Registration Services (US$8 million)

The objective of the sub-component is to support NIRA to scale-up BDR services at the health facilities and the communities. The project will support NIRA to (a) establish BDR mobile outreach services for effective coverage within 63 districts; (b) scale-up the Mobile Vital Records System (MVRS) for birth registration to an additional 54 districts; (c) expand birth registration to 218 HC IVs, and 1,300 HC IIIs; (d) expand mobile/outreach birth registration services to remote and underserved communities; (e) train facility and community-based registration personnel on BDR; (f) design the death registration module within the existing MVRS; (g) train clinical staff and Maternal and Perinatal Death Audit Committees on cause-of-death reporting according to International Classification of Diseases (ICD) guidelines; (h) develop a customized DHIS29 module for reporting cause of death and ICD coding; and (viii) acquire the necessary materials, tools and equipment for BDR (office equipment, IT equipment - computers and mobile phones - and BDR registers).

2.1.4 Component 4: Enhance Institutional Capacity to Manage Project Supported Activities

The objective of the component is to enhance institutional capacity for management of project supported activities. This component will support costs related to overall project management, training, and project operations (safeguards, M&E, citizen engagement) in order to ensure the intended objectives are achieved in a sustainable manner. The project will address the skills gaps in project management and build institutional capacity of the relevant units for efficient and effective project implementation. This will include the following:

1. Strengthen project management, including fiduciary capacity. This will entail enhancing capacity for project management, financial management, procurement, and both internal and external audit functions. This component of the project will additionally ensure that the required tools and equipment are available for project operations (such as office equipment and motor vehicles). 2. Strengthen capacity to implement RBF programs. Special attention will be paid towards training key staff in RBF design and implementation, as well as national coordination of the various RBF programs/schemes in the country. 3. Strengthen capacity for management of environmental and social safeguards related activities. This is to enable the MoH to plan, coordinate, monitor, and report on implementation of the relevant mitigation activities. 4. Enhance monitoring and evaluation functions. The project will support the resource center to generate reliable data to facilitate routine project monitoring, verification of RBF outputs, and coordination and implementation of the mid-term and end-of-project evaluation.

9 DHIS2 is a health management information system used 47 countries including Uganda, and used by 23 organizations

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5. Support information, education and communication and citizen engagement. This will involve engaging the media, revision and dissemination of appropriate tools, and materials on citizen engagement, and monitoring of citizen engagement related activities.

2.1.5 Component 5: Contingency Emergency Response Component (CERC) for Ebola and COVID-19 Response

Component 5 will provide for rapid allocation of funds to support recovery measures in case of Ebola outbreak in Uganda and strengthen the main response pillars of: Coordination and leadership, Surveillance, Case management and treatment, Logistics management, Risk communication and Vaccination and treatment

The background to CERC is that Ebola Virus Disease (EVD) outbreak in Democratic Republic of Congo (DRC) still prevails with over 2900 cases and 1961 deaths registered as of 21 August 2019. Since July 2019, EVD alerts are being reported to Uganda surveillance teams as close as less than 5 km from Ugandan border. Uganda shares more than 550 miles of border with DRC and thousands of people move between the two countries daily. Uganda has conducted preparedness interventions since 1 August 2018 in the 30 EVD high-risk districts and has continuously enhanced its preparedness activities as the risk of importation remains very high. Of the 30 EVD high risk districts, 15 (or half of them all) share a common border with DRC and face a high risk from EVD-infested regions of Congo. On average, over 800,000 people cross the border monthly putting Uganda at increased risk of EVD infestation. Because of this, Uganda was considered a priority country for enhanced preparedness.

On 11 June 2019, Uganda reported three EVD cases in Kasese District that borders DRC in Western Uganda and this was reportedly due to movement of people form DRC. Uganda initiated and sustained strong response measures for three months to control the outbreak. Nonetheless, major gaps were apparent, which need to be addressed to avoid recurrence of outbreak and also enable early detection and trigger of control measures. On 11 July 2019, World Health Organisation (WHO) declared EVD outbreak in DRC a Public Health Event of International Concern (PHEIC) after confirmation of EVD patient in Goma, DRC. Due to ease of movement of potentially infected people from DRC into Uganda, it is judicious for GoU to strengthen its emergency preparedness measures in high risk district local governments bordering DRC. These high-risk districts are shown in Table 1 and Figure below:

Table 1: Ebola risk-prone districts in Uganda Category Description Districts and description Very high risk due to their close proximity to zones 2 districts: 1 that have recently had new cases, direct trade routes or have had imported EVD cases. Kasese and Kisoro 10 districts: 2 High risk because they border DRC and have had direct routes to /from affected areas of DRC. Rubirizi, Bunyaruguru, Bundibugyo, Ntoroko, Kanungu, Arua, Kampala, Buliisa, Kikuube and Wakiso. 14 districts: Moderate risk: These require enhance 3 preparedness due to population movement from Kabale, Rukungiri, Kyegegwa, Kyenjojo, affected areas of DRC or are hosting DRC refugees. Isingiro, Kabarole, Kamwenge, Hoima, Kagadi, Packwach, Zombo, Nebbi, Koboko and Maracha. 4 Low risk: The rest of Uganda

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Figure 1: Districts with Ebola virus diseases (EVD) risk in Uganda

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A technical description of CERC is provided in Table 2 below.

Table 2: Description of CERC OBJECTIVES EXPECTED OUTCOME 1 Purpose of CERC: To maintain and strengthen EVD interventions in the high risk districts to prevent spillover and ensure containment in the event of an outbreak 2 Strategic objectives: To maintain capacities built and address gaps identified in different strategic pillars. The gaps were identified through needs assessment, Preparedness and Response Plan, and After-Action Reviews. i) Coordination and leadership:

a) Strengthen incident management from national to district a) Incident management system activated and functional in all level to enable a community-led EVD response mechanism districts to achieve coordinated preparedness and response. for 12 districts in Category 1 and 2 for 12 months. b) Strengthen evaluation and performance management by b) Evaluation and performance management systems the national and district coordination platforms to ensure established at national and district levels. coordination and accountability for 12 districts in Category 1 and 2 for 12 months. c) All high-risk districts have functional community-based surveillance systems capable of increasing and maintaining rapid detection, notification and response to EVD spill over/ outbreak. MoH indicated that while Batwa are prevalently not members of these surveillance structures, they are easily and always accessed by village health teams (VHT) operating in Batwa communities. ii) Surveillance and points of entry (POE) monitoring

a) Activate and strengthen community capacity for a) Functional cross-border surveillance systems between surveillance and reporting to enable early detection and districts and with Democratic Republic of Congo (DRC). response to all suspect EVD cases for 12 districts in Category 1 and 2 for 12 months. b) Screening, infection prevention and control and risk b) Strengthen point of entry screening and cross-border communication are reinforced at all official points of entry (POE) surveillance for all border districts with DRCongo and in all high-risk districts. enable information sharing and case identification for 12 districts in Category 1 and 2 for 12 months.

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OBJECTIVES EXPECTED OUTCOME c) Enhance surveillance systems for early detection and response to EVD in high risk districts. iii) Laboratory

Enhance laboratory testing and confirmation of samples from All high-risk districts will have capacity to immediately collect and high risk districts to enable quick detection hence invoke dispatch samples for laboratory confirmatory analysis. prompt response mechanisms for EVD in for 12 districts in Category 1 and 2 for 12 months. iv) Risk communication, community mobilisation and engagement Awareness and sensitisation about EVD is sustained among Create and sustain a high level of awareness on EVD in high communities (including Batwas) in high-risk districts to mitigate risk districts in order to reduce myths and misconceptions about myths and misconceptions. EVD in local communities for 12 districts in Category 1 and 2 for 12 months. v) Case management

Establish infection prevention and control programs at health All health facilities in high-risk districts have adequate infection facilities level with appropriate logistics to prevent EVD spread prevention and control measures and logistics to prevent EVD for 12 districts in Category 1 and 2 for 12 months. amplification and spread. vi) Water, Sanitation and hygiene (WASH)

Enhance water, sanitation and hygiene interventions in All congregational settings in high-risk districts are fully aware of congregational settings including schools, markets and the WASH intervention, able to utilize and maintain existing hospitals to avert possible spread of EVD for 143 districts in WASH facilities. Category 1, 2, 3 and 4 for 12 months. vii) Vaccination

Improve perceptions on vaccination against EVD and the use of Improved perceptions on vaccination against EVD and use of therapeutics in affected communities for 12 districts in Category therapeutics in affected communities. 1 and 2 for 12 months.

Table 3: CERC budget for EVD

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Pillar National Category 1 Category 2 Category 3 Total (Ushs) Total (USD) (1 district) (10 districts) (13 districts) Coordination and leadership 448,700,000 223,600,000 169,200,000 0 841,500,000 224,400 Surveillance & POEs 1,062,000,000 1,829,080,000 3,678,010,000 0 6,569,090,000 1,751,757 Laboratory 897,800,000 d 5,000,000 0 904,800,000 241,280 Risk communication, social 6,875,000 435,600,000 584,000,000 0 1,026,475,000 273,727 mobilization and community engagement Case Management 1,307,259,752 2,919,472,000 72,472,000 0 4,299,203,752 1,146,454 IPC and SDB 1,100,000,000 478,184,000 318,284,000 0 1,896,468,000 505,725 WASH 1,201,200,000 35,750,000 0 0 1,236,950,000 329,853 Logistics 1,350,000,000 132,102,000 493,995,000 0 1,976,097,000 526,959 EVD vaccination & investigational therapeutics 0 0 0 0 0 0 Total 7,373,834,752 6,053,788,000 5,320,961,000 0 18,750,583,752 5,000,156

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Uganda has widely recognized success story in effectively responding to EVD, preventing its spread once detected. For example for the outbreaks in June and August 2019 (in both periods patients came from Democratic Republic of Congo):

. All cases were quickly identified due to existing strong surveillance systems, . Suspects were quickly detected and identified, isolated and treated, . All (100%) people with which patients had contact were also identified and vaccinated which prevented further transmission in Uganda in both periods. . Overall, EVD Emergency Response was well coordinated, the public effectively sensitized and all EVD Control pillars functioned efficiently.

In addition, Uganda prepared a Contingency Plan and SOPs to serve as key guiding documents to manage EVD response activities.

Generally response objectives are: a) Detect all cases of EVD in affected areas and identify contacts. b) Trace and follow all contacts. c) Strengthen rapid response capacity for the EVD outbreak. d) Reduce risk of EVD transmission in the community and nosocomial transmission in health facilities. e) Promote good individual and collective practices through risk communication, social mobilization and community engagement to prevent the spread of EVD f) Strengthen the capacity of the national and regional laboratories to diagnose EVD. g) Ensure clinical and psychosocial care of patients, convalescents and staff involved in the management of EVD outbreak. h) Strengthen the capacity of neighboring countries (especially DRC) at risk for early detection and response to imported cases of EVD, including exit screening.

2.1.5.1 Surveillance, active case finding, contact tracing and investigation of cases

Surveillance, active case finding, contact tracing and investigation of cases entail rapid detection and isolation of new cases to prevent onward transmission of EVD. This requires medical teams, supported by a laboratory service able to provide rapid, safe and accurate testing of samples. Key activities are as follows:

. Deployment of epidemiologists at the national and local levels. . Conducting a retrospective and prospective evaluation at the health structures and in the community to better describe the ongoing outbreak. . Reproducing and dissemination of guidelines. . Setting up records of EVD cases and deaths in all health facilities in the province. . Organize active case finding. . Identify all contacts and placing them under daily surveillance for 21 days for symptoms. . Alerting all health zones in the province and prepare hospitals and health centers in large cities. . Analyzing epidemiological data and provide feedback.

2.1.5.2 Case management

Case management aims to ensure that all patients have access to high quality medical care not only to improve survival, but also to provide symptom relief and palliative care when required. Care must be provided whilst taking stringent precautions to minimize risk of onwards transmission to others, including health workers. Effective triage and infection prevention and control ensures access to other health services will continue despite the outbreak. Key activities are as follows:

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. Evaluating and map current capacities of health facilities in terms of protocols, human resources, infrastructure, supplies and equipment. . Recruiting additional clinical staff in affected areas. . Setting up isolation units in each of the health areas affected by the outbreak. . Supporting isolation units with essential drugs and the necessary equipment. . Support all hospitals and health centers in affected districts. . Providing maximum protection for staff assigned triage and care for patients. . Ensuring effective transportation of patients and safety of all involved in the referral pathway.

2.1.5.3 Infection prevention and control in health facilities and communities

Infection prevention and control (IPC) is crucial in containing the spread of EVD. Robust IPC measures and practices need to be in place at all health facilities, as well as in the communities. Key activities are as follows:

. Strengthening IPC in all health facilities in affected districts. . Training staff in IPC measures and techniques . Equipping personnel of health facilities with IPC materials and equipment (chlorine for disinfection of people, safety clothing and equipment, etc). . Training communities in hand washing, avoid shaking hands, report suspected victims to health centers, avoid communal handwashing and burials besides other hygiene methods. . Equipping communities with materials and equipment for hand washing. . Ensuring supply of health facilities and communities with water. . Ensure safe and dignified burials of EVD patients through establishment of safe and dignified burial teams and household decontamination teams. . Ensure proper waste management of EVD contaminated materials. . Ensure IPC compliance during transportation of patients.

2.1.5.4 Risk communication, social mobilization and community engagement

Past experience has shown that affected communities hold the key to preventing the transmission of EVD. Listening to the concerns of communities and providing appropriate and well-targeted information to them maximizes the effectiveness of all aspects of the response. Key activities are as follows:

. Mapping of villages and communities in affected health areas. . Producing a National Communication Plan on EVD. . Identifying community and religious leaders. . Organizing and training communication and social mobilization teams. There should be specific activities targeting Batwas since they might not be effectively engaged through conventional/ mainstream approaches. For instance this should entail reaching out to Batwa people through their local representatives. . Establishing / equipping teams with communication tools and materials. . Producing communication messages for different media and apply social mobilization tools. . Conducting interpersonal and mass communication sessions (local radios and others). . Conducting a knowledge, attitude and practice (KAP) survey.

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2.1.5.5 Psychosocial care

An essential component of case management is psychosocial assistance. EVD survivors and family members of EVD cases are often stigmatized, and unable to resume their lives following recovery. It is important therefore that psychosocial care is integrated in the response at the earliest stage. Key activities are as follows:

. Training providers and community leaders on essential psychosocial care. Specifically here, unique approaches should be devised to ensure effectives involvement of Batwa indigenous people. . Equipping teams with appropriate trainings, tools and support. . Providing food / nutrition and non-food support (clothing, utensils, etc) to affected individuals and families. . Establishing a psychosocial action plan to combat stigma and other consequences. . Assisting in the care and social reintegration of survivors and orphans.

2.1.5.6 Operational and programme support

Key infrastructure, procedures, and operational support mechanisms must be put in place to enable all aspects of the response. Key activities are as follows:

. Mobilizing experienced human resources to strengthen the response. . Mapping of interventions and the coordination of logistical capacities. . Transportation of teams and equipment at all levels. . Providing logistical and communication support to epidemiological surveillance teams (equip teams with supplies, communication tools, including phone credits). . Organizing workspaces and living arrangements.

2.1.5.7 Strengthening the capacity of health staff to respond to EVD outbreaks

With the recurrence of EVD outbreaks in the Democratic Republic of the Congo, it is important that the response to the ongoing outbreak also build the capacity of health personnel in epidemiological surveillance, IPC and case management. Key activities are as follows:

. Reproducing technical sheets on EVD and provide refresher trainings to health providers on case management. . Training and coaching management teams from health zones in affected districts in epidemiological surveillance of EVDs and IPC. . Training and coaching health center personnel of affected districts, in EVD surveillance and early warning. . Training community relays in active case finding and community-based surveillance for early detection of EVD. Special attention should be given to training health providers involved with Batwa people. . Following up with trained health staff in Integrated Disease Surveillance and Response (IDSR).

2.1.5.7 Contingency Emergency Response Component (CERC) for COVID-19

Uganda has developed a six-months National COVID-19 Preparedness and Response Plan covering a period March 2020 to April 2021 costing US$ 44.7 million based on the most likely scenario of confirming a few cases in one geographical location. This scenario involves management of confirmed case(s); enhanced surveillance; risk communication, community sensitization and engagement; Infection Prevention and Control and WASH; Psychosocial support activities; District categorization and preparedness focused in high risk districts and response in affected areas. However, following declaration of COVID-19 as a pandemic by WHO on March 11, 2020, the government upgraded the planning scenario for preparedness and response to the worst-case scenario (also termed Scenario 3) i.e. confirming cases in multiple locations or overwhelming numbers of cases. The worst - case scenario provides for wider implementation of interventions nation-wide in a multi-sectoral model using the One Health Approach. It requires cross pillar response at community level, points of entry escalate to response capacities, surge

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team human resource, escalation of response activities to NECOC and Office of the Prime Minister and intensified patient care. The goal of this plan is to provide a framework for prevention and rapid control of COVID-19 by delaying importation, strengthening containment, reduction of morbidity and mortality; and mitigation of economic and social disruption occasioned by COVID-19 outbreak. Uganda government has considered planning scenarios shown in table below, to contain the COVID-19 pandemic.

Table 4: Planning scenarios for COVID-19 control in Uganda Scenario Actions Scenario 1: Best case scenario Development of contingency plan, Enhanced surveillance and screening at No cases reported in Uganda. points of entry; Prepositioning of logistics at PoEs and regional referral hospitals; conduct risk communication and community engagement; IPC and WASH; District categorization and preparedness focused in high risk districts, build surge capacity and conduct simulation exercise (SIMEX) Scenario 2: Most likely scenario Management of confirmed case(s); Enhanced surveillance; Risk Confirmed cases in one communication and community sensitization and engagement; Infection geographical location, enhanced Prevention and Control and WASH; Psychosocial support activities; District preparedness across the country categorization and preparedness focused in high risk districts and response in affected areas Scenario 3: Worst case scenario Cross pillar response at community level, points of entry escalate to Confirmed in multiple locations, or response capacities; Escalation of response activities to the NECOC under overwhelming numbers of cases OPM; Surge teams (including the UPDF and international medical teams)

Uganda confirmed its first coronavirus case on 22 March 2020 and eight more cases were recorded by 24 March 2020. Therefore Scenario 1 is no longer applicable. From the experience in China, South Korea and Italy, which had exponential escalation of cases, Uganda will focus preparedness on “Scenario 3”. This will strengthen national capacity to delay importation of COVID-19, detect and isolate cases early, and manage those that progress to severe and critical stages appropriately. Already (as of 22 March 2020), Uganda has banned all passenger flights into the country and closed borders to human traffic.

Whereas the whole country is at risk, some locations are at higher risk because of various characteristics including: location of international airport, international borders, high human traffic (such as cities and big municipalities) and location of regional referral hospitals, which are being prepared as potential isolation and treatment centers. These locations, which are the most probable sites in the Scenario 3 assumption, are:

. Districts with Regional Referral Hospitals (16): Arua, Gulu, Soroti, Lira, Mbale, Moroto, Tororo, Jinja, Naguru, Kampala, Hoima, Mubende, Fortportal, Wakiso-Entebbe, Masaka, Mbarara

. Border districts with affected neighboring countries (27): Kikuube, Bulisa, Busia, Kisoro, Kabale, Ntungamo, Kasese, Ntoroko, Kagadi, Arua, Koboko, Amuru, Tororo, Madi Okollo, Isingiro, Rakai, Busia, Mubede, Kalangala, Kabaale, Amudat, Kyotera, Bukwo, Moyo, Lamwo, Budibujjo, Namusidwa

Based on global statistics, it is assumed that 5% of the total number of cases will be critical cases that require care Intensive Care Unit (ICU), 15% of the total number of cases will be severe and will require hospitalization in an isolation facility while the rest of the cases (80%) will be mild and may not require hospitalization (can be managed from home). Uganda has 16 regional hospitals in which each ICU has only 10 beds. Countrywide, the maximum number of critical cases that can be handled are therefore 160. This reiterates the importance of fact that prevention of the COVID-19 infection over management is preferred to managing it afterwards. Uganda plans to pursue prevention and control of COVID-19 by delaying importation, interrupting transmission early and fast, minimizing morbidity and mortality as well as mitigating economic and social disruption that may result from this outbreak. This objective will be achieved through the following strategies:

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. Development of country capacity for early detection, confirmation, reporting and referral of suspected cases to designated isolation units; . Development of capacity for case management including management of severe case; . Raising of public awareness on risk factors for transmission, prevention and control of COVID-19; . Strengthening of infection prevention and control measures required to mitigate spread of COVID-19 in health facilities, institutions and at the community level; . Strengthening of capacities for coordination, data management and surge capacity; and . Application of multi-sectoral approach to minimize social and economic impact.

2.2 Project Financing

The project is financed through an Investment Project Financing (IPF) instrument. Out of the total project cost of US$140 million, US$110 million is financed under the IDA Credit, and US$30 million from the Global Financing Facility (GFF) grant. Financed by the World Bank, Ebola CERC is budgeted to cost US$ 5 million. CERC funds will enable support and expansion of Ebola preparedness and response. CERC-IP funding amounting to US$ 5 million will be reallocated from Component 1 (Results-Based Financing for Primary Health Care) and Component 2 (Strengthen Health Systems to Deliver URMCHIP Services) of the Project.

Preliminary estimates put the cost of COVID-19 Scenario 3 plan at US$ 44.7 million over a period of one year. The breakdown of this cost is shown in table below.

Table 5: Funding required for Scenario 3 COVID-19 Response Plan over a year

Pillar Budget (US$) Coordination and leadership 317,241 Surveillance, laboratory support & POEs 861,734 Risk communication, social mobilization and community engagement 1,353,076 Case management, infection prevention and control 3,517,649 ICT and Innovation 51,933 Mental health and Psychosocial support 1,084,865 Logistics 37,531,913 Total 44,718,409

2.3 Anticipated Social and Environmental Impacts

The project involves minor civil works that include the construction of 40 maternity units in existing HC IIIs as well as minor renovations. While the probability of land acquisition under the project is quite limited, since the exact sites and land take needs are uncertain, the project may have resettlement and land acquisition impacts and triggers the social safeguards policy OP/BP 4.12. To mitigate any possible impacts, a Resettlement Policy Framework (RPF) has been prepared to guide resettlement and compensation of project affected persons in a sustainable manner. The resettlement policy framework will apply to components 1 and 2 of the project whether or not they are directly funded in whole or in part by the Bank; and compensation will be a prerequisite for implementation to begin.

The project‟s geographical coverage includes among others some districts traditionally occupied by indigenous people (IPs): the IK in Kaabong District and the Batwa in some districts in western Uganda. To ensure that social development outcomes of inclusion are achieved, the project triggers safeguards policy OP/BP 4.10. An Indigenous People‟s Plan (IPP) and an Indigenous People‟s Policy Framework (IPPF) have been prepared for the IK and Batwa, respectively. Free, prior and informed consultation (FPIC) with indigenous peoples‟ communities was carried out with the Ik and the Batwa communities. Some of the identified potential positive effects on Indigenous Peoples from

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project implementation include increased use of available health care services, delivery of culturally appropriate services including nutrition related interventions, and improved access to health services through outreach services. The project will promote socio-cultural interaction, coordination and consultation with traditional leaders prior and during project implementation. For this, it is essential that districts employ staff in the health facilities who speak the local dialects and are compliant with local socio-cultural interaction norms and belief systems of the IPs.

The interventions under the project involve improvement in provision of health services, construction and renovation of health facilities, as well as handling of medical products. These activities will contribute to improved health services and subsequently to increased generation of medical waste in the health facilities. Component 1 and Component 2 involve, inter-alia, small scale infrastructure works, renovations/expansion, electric power extension, water supply, fencing, and health care waste management (HCWM). The project expects to construct 40 maternity units at HC-IIIs. The civil works will pose health and safety issues, including construction waste aspects, while the health care waste will pose health risks to the patients, attendants, health workers and the public in the event of poor management practices. The potential environmental impacts can be adequately managed by integrating environmental due diligence into the sub-project cycle. Consequently the project triggers the following Environmental Safeguards Policies: Environmental Assessment OP/BP 4.01, and Physical Cultural Resources (PCRs) OP/BP 4.11 because of the civil works that may encounter unknown physical and cultural resources. Owing to the overall limited likely environmental and social impacts, the project is rated as EA category B.

Because the exact participating facilities and their location are not yet known, and it is not clear whether or not the project could lead to acquisition of additional land and or loss of livelihoods of some individuals or communities, an Environmental and Social Management Framework (ESMF) have been prepared through a consultative process to guide handling of project environmental and social aspects during implementation. The ESMF includes environmental and social management tools such as screening procedures for sub projects, determining extent of required environmental assessment and assessment of environmental and social impacts that may arise from the construction of the new maternity wards, assessment checklists, environmental and social management plans, simplified/practical health facility (HC-III/IV) health care waste management guidelines, chance finds procedure, environmental and social reporting formats, stakeholder and community engagement plan, HIV/AIDS management plans, child protection and gender responsive plan, and grievance redress mechanism to handle complaints raised by project workers and/or project affected persons. This ESMF sets out how the environmental and social impacts will be considered in the sub-project cycle. Given that the project may involve construction and labor concentrations and movement, the ESMF provides guidance that is in line with the National Labor laws and management of workers, including a Code of Conduct. Upon identification of the participating health facilities, site specific environmental assessments and respective Environmental and Social Management Plans (ESMPs) shall be prepared during project implementation.

In addition to the National Health Care Waste Management Plan (2009/2010 – 2011/2012) prepared and disclosed under the previous IDA projects, the MoH has the following documents on health care waste management and infection control: Approaches to Health Care Waste Management (HCWM), Health Workers Guide, Second Edition (2013); Uganda National Infection Prevention and Control Guidelines (December 2013); and the National Policy on Injection Safety and Health Care Waste Management (2014). These documents shall guide management of HCW and shall form part of the project ESMF. The listed guidelines shall be harmonized into one basic practical guide in the Project Implementation Manual used at both HC-IIIs and HC-IVs to manage HCW. HCWM shall be part of the assessment criteria for participating health facilities including development of a site specific HCWM-Plan.

Environmental compliance is the responsibility of the Environmental Health Division (EHD) of the MoH which is charged with coordination of health care waste management activities under the overall policy guidance of the National Environment Management Authority. However, the EHD has not fully participated in the implementation of Uganda Health Systems Strengthening Project (P115563). Their functionality and capacity to handle environmental and social Safeguards requirements was assessed during preparation of the ESMF and appropriate remedial measures were suggested to address the gaps that were found. In order to ensure proper implementation and management of the environmental and social aspects of the project, the MoH will hire an Environmental Health

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Specialist as part of the project coordination team. The specialist shall closely work and coordinate with the District Environment Officers and Community Development Officers and related partners on a day to day basis. Relevant safeguards training of project staff, participating health facilities & Local Governments shall be undertaken early enough at the start of the project. During project implementation the MoH shall ensure clear coordination between the MoH and relevant national and/or local government agencies.

Climate change and disaster risk screening. The project was screened for short and long-term climate change and disaster risks. The results indicate Uganda may be slightly exposed to climate risks with regards to drought, flooding and precipitation, and landslides; however, the overall risk is low with low potential impact. Therefore, no regular assessments of potential climate change impacts will be carried out during the project period.

Satisfactory containment of COVID-19 pandemic would avoid potential grave socio-economic impact on Ugandan people. Currently the country has lowered its economic growth projection for this financial year by 0.3% to 0.8% from the targeted 6 percent for financial year 2019/2020. Schools and many other facets of public life have been shut down. In its worst scenario therefore, COVID-19 will impoverish millions of Ugandans.

Beside loss of life, uncontrolled spread of COVID-19 in Uganda would have significant socio-economic impact on the country. The biggest impact would be on the services sector. Travel restrictions are already affecting the tourism sector including hotels, accommodation and transportation. Border closures and supply chain disruptions are hampering cross-border trade. Closure of learning institutions, public places and places worship is disrupting social, cultural and religious life of people.

Medical waste from COVID-19 emergency operations will be managed similarly to all other medical waste using the same facilities and management systems.

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3 BASELINE BIOPHYSICAL AND SOCIO-ECONOMIC ENVIRONMENT

Existing environmental and socio-economic conditions in Uganda are discussed in sections below and will, in many cases, provide a basis for predicting impacts of the project.

3.1 Location

Uganda (located in East Africa) has an area of 241,500 km² and is bordered by Sudan to the North, the Democratic Republic of the Congo to the west, Tanzania and Rwanda to the South and Kenya to the East.

Source: UBOS, 2012 Figure 2: Regions in Uganda

3.2 Climate

Climatic conditions in Uganda are discussed below.

a) Uganda is characterized by equatorial climate with plenty of rain and sunshine moderated by the relatively high altitude. In most parts of the country, the mean annual temperatures range from 160C to 300C. Nevertheless, the Northern and Eastern regions sometimes experience relatively high temperatures exceeding 300C and the South Western region sometimes has temperatures below 160C. The Central,

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Western and Eastern regions have two rainy seasons, from March to May for the first rains, and the second rains from September to November. The Northern region receives one rainy season from April to October, and the period from November to March has minimal rain. Most of the country receives between 750 mm and 2100 mm of rain annually.

Source: NEMA (2009) Figure 3: Uganda rainfall map

b) Uganda's climate is naturally variable and susceptible to flood and drought events which have had negative socio-economic impacts in the past. Human induced climate change is likely to increase average temperatures in Uganda by up to 1.5 ºC in the next 20 years and by up to 4.3 ºC by the 2080s. Such rates of increase are unprecedented. Changes in rainfall patterns and total annual rainfall amounts are also expected but these are less certain than changes in temperature. The climate of Uganda may become wetter on average and the increase in rainfall may be unevenly distributed and occur as more extreme or more frequent periods of intense rainfall. Regardless of changes in rainfall, changes in temperature are likely to have significant implications for water resources, food security, natural resource management, human health, settlements and infrastructure. In Uganda, as for the rest of the world, there are likely to be changes in the frequency or severity of extreme climate events, such as heat waves, droughts and floods.

Relation to the project: Climatic conditions can influence rain received in a given project area, sunshine hours, flood levels and winds all of which could affect, in various ways, the proposed project such as construction schedules or inability to deliver construction materials and healthcare supplies (during project implementation) when roads are cut

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off by floods. Weather conditions that damage roads or preclude access to EVD risk-prone areas would delay emergency response to Ebola outbreak. 3.3 People and Cultures

An outline of the people of Uganda is provided below.

3.3.1 The People

The Uganda constitution 1995 recognizes 46 tribes (GoU 1995) with varying production and consumption patterns. Modes of production and the rural livelihood coping strategies range from mainly cultivators (e.g. Baganda, Bakiga, Bagisu and Basoga) to pastoralists (e.g. the Karamojong and the Bahima) the rest of the people derive their livelihoods from a mix of livestock keeping and cultivation or agro- pastoralism. In addition, Uganda has been and still is, home to several thousand refugees from neighboring countries. There are also other non-citizens residing in Uganda as a preferred place for home or where they are engaged in various economic activities. This mosaic provides Uganda with a rich cultural base and opportunities for modernization. However, there are also challenges the people of Uganda face, among others are: (i) rapid population growth and the ensuing pressures on the country‟s natural capital; (ii) inadequate provision of, and demand for, social services and infrastructure; and (iii) poor environmental conditions.

Batwa found in several south-western districts with high Ebola risk, especially Bundibugyo, Rukungiri, Kisoro and Kasese are one of the Vulnerable and Marginalised Peoples (VMP) of Uganda10 who often lack access to healthcare and socio-development programs. Shunning conventional communication channels, Batwa require ingenious approaches (e.g. training their opinion leaders first) to ensure effective sensitization about EVD potency, symptoms, control measures and how to report suspected victims in their midst.

Relation to the project: Health attributions influence health beliefs and health behaviors. Health attributions are partly shaped by culture. In turn, cultural health attributions affect beliefs about disease, treatment, and health practices. Likewise, culture influences health and healing practices. Certain cultures have culture-bound syndromes about which medical practitioners should know. Culturally diverse patient populations and indigenous peoples (such as Ik in Kaabong and Batwa in South-Western Uganda) require that medical practitioners are aware of potentially unique needs, attitudes, cultural practices and behavior of local communities that will receive healthcare services under this project.

Using existing socio-cultural structures, these indigenous people should be sensitized, and awareness created early so that in case of EVD outbreaks, Batwa people are aware of what EVD is, symptoms, ways by which it is spread, prevention precautions and the importance of adhering to emergency control measures imposed by government.

3.3.2 Population Dynamics

In Uganda, the 20th century marked an unprecedented population growth and economic development as well as environmental change. The Census report of 2002 put the country‟s population at 24.7 million people in 2003. The current growth rate of 3.4% per year is higher than the 2.9% that was envisaged for the period 1991 – 2002. Currently standing at 34 million, population of Uganda is likely to hit 50 million by 2025. Population is a key determinant of economic and social wellbeing and environmental degradation.

10 Ministry of Gender, Labour and Social Development, 2017: Uganda Management of Social Risk and Gender Based Violence Prevention and Response Project. The 5-Year Indigenous Minority Peoples Plan (IMPP)

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The projected mid-year population size in millions for each year from 2003 to 2017 is given in figure below. The population of Uganda is estimated to increase from 28.6 million in 2007 to 40.6 million in 2017 in the Low Variant, while in the High Variant it is estimated to increase from 30.2 million in 2007 to 43.4 million in 2017.

Source: Population Secretariat, 2010 Figure 4: Population projections for Uganda (for high and low fertility rates)

Figure 5 below shows population distribution by district in Uganda.

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Figure 5: Population distribution in Uganda

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Relation to the project: With its high fertility levels and youthful age structure, Uganda is currently a pre- demographic dividend country. Even if fertility rates were to reach replacement level immediately, Uganda will continue to experience significant population growth, as relatively large population of children enter their reproductive years and bear children. The demographic transition (i.e. transition from high birth and death rates to low birth and death rates) remains sluggish and undermines Uganda’s growth prospects as population growth strains the supply and access to social services including healthcare.

3.4 Natural Resources

3.4.1 Atmospheric Resources

In Ugandan climate change and climate variability impose adverse impacts on livelihoods, especially of the rural poor. The country is a net sink for greenhouse gases but global climate has no physical borders, hence Uganda is also impacted by increase and fluctuation in the earth‟s temperature. Increased frequencies of floods and droughts are manifestations of climate change. These effects invariably have public health impacts.

3.4.2 Land as a Terrestrial Resources and its relation to the project

Due to a high rate of population growth, land continues to be increasingly scarce in urban and peri-urban areas where, incidentally, many healthcare facilities are located.

Relation to the project: In many cases this has led to encroachment of land belonging to the healthcare facilities.

3.4.3 Energy as a Cross-Sectoral Resources

The dominant source of energy in Uganda is biomass and this is expected to remain so in the foreseeable future in spite of government‟s intensified effort to increase investment in energy generation and distribution.

Relation to the project: Access to power supply has a direct correlation with capacity of a given healthcare facility to provide specific services reproductive, maternal, neonatal and child health medical services. For example health centers without reliable power supply cannot carryout emergency medical operations including caesarean births.

3.5 Socio-Economic and Cultural Environment

3.5.1 Human settlements, housing and urbanizations

In general and particularly in rural areas, settlement patterns are wasteful of land and increase the cost of providing services to the areas. The settlements are also largely unplanned; and where plans exist they are often not adhered to. The quality of Ugandans‟ housing has improved over the years. When compared to the situation in 1991 where over 85% of the households in both urban and rural areas has rammed earthen floors, by 2002 only 29% urban and 77% rural households had them.

Although Uganda is one of the least urbanized countries in the world in absolute terms, the urban population is growing. Beginning from about 635 00 in 1969, the urban population increased to 938 00 in 1980, 1,890,000 in 1991 and 292,200 in 2002. The urban population is also growing faster (3.7%) than the national average (3.4%). The growth in the urban population means that pollution issues such as solid wastes management, and the provision of adequate safe water and acceptable level of sanitation coverage will have to be addressed.

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Relation to the project: Increasingly, unplanned settlements and weak (or lack of) enforcement of physical planning guidelines in many fast growing and sprawling urban and peri-urban areas has led to prevalent encroachment of land owned by medical facilities.

3.5.2 Safe water and sanitation

Access to safe water and sanitation in both urban and rural areas has increased compared to the situation 10 years ago. For example in 1991, only 11 towns had the services of the National Water and Sewage Cooperation (NWSC) but now the corporation covers 19 towns. By 2004, rural access to safe drinking water had increased to 57% while the urban one was at 67%. If current trends continue, and incremental investment funds are procured, Uganda should meet its Millennium Development Goal on water supply. While safe water access per se has improved, functionality of water points is another key issue. Also, the costs of water in urban areas and the distance travelled to and queuing at water points in rural areas easily undermine accessibility. As far as sanitation is concerned, latrines coverage, the board indicator (as a measure) of environmental health had improved from 41.7% in 1999 to in 2002.

Relation to the project: Availability of adequate water for drinking and sanitation is still a challenge in areas in the country. There is a direct relationship between lack of access to safe drinking water and sanitation facilities and disease burden in communities.

3.5.3 Environmental pollution

As Uganda‟s urban areas increases in number and the urban population grows, pollution of air, noise and water are emerging as significant issues in socio-environmental challenges with significant health implications. Standards have been established for noise, air quality and wastewater discharge but enforcement is low.

Relation to the project: Research done in Uganda showed a direct relationship between air pollution and acute respiratory infections among children (Sansa, 2005).

3.5.4 Poverty

A May 2013 Poverty Status Report released by Uganda‟s Ministry of Finance Planning and Economic Development (MFPED) indicates that poverty levels among Ugandans have continued to decline, a trend that gives hope that the country‟s economy will continue to grow. According to the study report, the country‟s poverty levels have been on the downward trend since 1992 except in 2002/03 when a survey indicated that poverty levels had gone up. The number of people who are absolutely poor was 9.9 million (56.4%) in 1992/93 and reduced to 7.4 million (33.8%). Uganda has surpassed the Millennium Development Goals (MDGs), target on halving poverty by 2015, and made significant progress in reducing the population that suffers from hunger, promoting gender equality and empowering women. However, according to the World Bank11 the risks to Uganda‟s economic prospects are significant and mainly relate to poor performance in the area of domestic revenue mobilization, low levels of productivity of both agricultural and non-agricultural sectors; inappropriate urban development; the slow development of infrastructure; and the limited availability of credit.

Relation to the project: Declining poverty levels mean that even more people will afford not only afford access to healthcare services but can also educate their children with the resultant effect of reduced household disease burden. Reducing poverty even in rural areas means that people prefer to travel on commuter motorcycles (“boda- boda”) instead of walking long distances. This coupled with changing household food consumption trends may lead to increasingly prevalent incidence of lifestyle diseases.

11 http://www.worldbank.org/en/country/uganda/overview (accessed 4 April 2016)

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Plate 1: Passengers on a commuter motorcycle (or “boda-boda”)

3.5.5 General Health Statistics

Key health statistics in Uganda are outlined below12:

. In 2011, Uganda Government owned the highest percentage (46%) of hospitals in the country followed by private Not-For-Profit entities at 43% while private For-Profit organizations owned 11%. . In 2011, polio immunization coverage was 95 % among the children below 5 years of age. . In 2010/11, there were 34.9 million Out Patients Department (OPD) visits as compared to 36.8 million visits in 2009/10 in government and private Not-For-Profit healthcare facilities. . Latrine coverage at national level has continued to improve for the last five years, standing at 71 % in 2010/11 from 69 percent in 2009/10. . Malaria remains the highest cause of both morbidity and mortality among the children below 5 years of age. This is the age at the bottom of the primary school-going children and prevalence is higher in rural areas.

3.5.6 State of EVD Preparedness in Uganda

Uganda‟s Ebola Virus Disease (EVD) preparedness and response have capacity gaps that need urgent attention to be able to effectively respond to a potential outbreak of the disease. The gaps were revealed from a simulation exercise13 conducted in Wakiso (Entebbe) and Kasese (Mpondwe and Kagando) districts in early April 2019. The exercise tested functionality and coordination emergency systems, identified weaknesses and proposed urgent actions for improvement. It critically evaluated readiness at national, district and community levels.

Among challenges identified was inadequate coordination and communication between the Public Health Emergency Operations Centre, district authorities and health workers in Ebola Treatment Units (ETUs) and at Points of Entry (PoEs). In a real EVD outbreak, this challenge would delay identification, transfer and management of EVD patients.

The exercise noted that surveillance preparedness had gaps in designation and preparation of isolation areas, tracing of contacts and security at ETUs for patients and property. At Mpondwe border Point of Entry and at Kagando hospital, major gaps identified included inconsistent screening of travellers, inadequate deployment of screening staff, and improper use of Personal Protective Equipment (PPE) and poor observance of infection prevention and control (IPC) protocols. Case definition forms were also not available at Mpondwe PoE.

12 UBOS 2012, Statistical Abstract 13 https://reliefweb.int/report/uganda/uganda-simulates-ebola-outbreak-and-identifies-gaps-preparedness-and-response (Accessed: 20Nov2019)

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Regarding case management, inadequacies manifested in patient management; use of personal protective gear by health workers; knowledge on preparing chlorine solution; observance of the five moments of hand hygiene14; waste management; and adherence to the buddy system. Others gaps were on patient documentation and signage in the ETUs. The exercise also revealed inadequate disinfection of surfaces, low adherence to infection prevention and control (IPC) protocols and poor handling of patient property which could expose medical teams people to Ebola. At ETUs, the exercise identified a lack of well-defined roles for laboratory teams which affected sample collection and management. Risk communication preparedness was also noted weak.

Merits identified by the exercise were that the National Task Force was quickly able to mobilize different actors to respond to an EVD outbreak in record time. Communication between the Public Health Emergency Operating Center (PHEOC), and public health emergency sites was noted excellent. Primary and secondary screening at PoEs and in communities was effectively carried out. There is adequate supply of materials such as thermometers, protective gear, hand washing facilities and chlorine in all the sites an indication that the country has taken major prevention and control precautions against EVD outbreak. ETU at Bwera was noted to be adequately prepared and its health workers demonstrated good knowledge of EVD management. The unit was also well maintained with good hygiene, waste management and had adequate supply of wash water. There was good collaboration between security and health workers at Mpondwe PoE. The exercise also found heightened community risk perception pointing to the good work done on community engagement and risk communication. The Village Health Teams, especially in Kasese district, were prepared and demonstrated ability to identify suspect EVD cases and promptly disseminate information within in the community. Ambulances were found in all designated areas ready to transport EVD patients as required in an outbreak situation. Logistics such as PPEs, infrared thermometers and hand washing facilities were found in all places as required and users knew how to operate them. Uganda has also prepared Contingency Plan and SOPs for EVD emergency response.

Relation to the project: Weaknesses identified in the national EVD response system points justify this project which will close existing gaps so the country is better placed to effectively and quickly respond to EVD outbreak.

3.5.6 State of COVID-19 Preparedness in Uganda

Uganda government has prescribed measures (see Annex 17) the public must follow to control COVID-19 pandemic. The ministry of Health has also developed and emergency action plan (EAP) whose goal is to provide a framework for prevention and rapid control of COVID-19 by delay of importation, containment, and reduction of morbidity and mortality; and mitigation of economic and social disruption resulting from the outbreak. a) Testing: Uganda government provides free COVID-19 testing services to those who have met criteria for being tested. If anyone feels they have COVID-19 symptoms, they are advised to visit a nearby health facilities at which they would be examined by a doctor. If the symptoms are matching that of coronavirus, the patient information will be sent to the coronavirus Incidence Commander at the Ministry of Health, who will respond by sending field epidemiologists. The patient will then be quarantined and samples taken brought to Uganda Virus Research Institute (UVRI) which has capacity to carry out up to 700 tests at once. b) Reporting: Toll-free numbers have been issued to the public to report COVID cases/ risks (as of March 25, 2020 these Toll-free lines are: 0800-203-033 and 0800-100-066) c) Multi-stakeholder partnerships: Ministry of Health has partnered with International Air Ambulance (IAA) a healthcare insurance provider, in managing COVID-19 emergencies and use its 200 service providers across the country to refer suspected patients to government gazetted facilities. As a first step IAA will manage someone out of danger, get suspected patients in touch with a gazetted hospital and clear associated bill. IAA healthcare

14 The five moments of hand hygiene are: 1) before touching a patient, 2) before clean/aseptic procedures, 3) after body fluid exposure/risk, 4) after touching a patient, and 5) after touching patient surroundings.

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service providers (private clinics or hospitals) across the country will provide basics services like managing patients‟ temperature and provide pain killers to contain acute pain. d) Public sanitisation and monitoring: All entry points (borders and airports) have passenger thermal temperature scanners and alcohol-based hand sanitizers. All public places have also been directed to provide hand sanitisation. All borders have been closed and passenger flights banned to avoid importation of COVID-19 into Uganda.

Hand sanitization is now mandatory before boarding public COVID-19 screening in Arua16 transport in Uganda15.

Figure 6: Some measures used by the public to control COVID-19 in Uganda

15 Source: https://www.monitor.co.ug/News/National/We-are-ready-coronavirus-health-experts-in-Uganda-/688334-5495810- hb1y66/index.html) Accessed 24March 2020 16 https://ugandaradionetwork.net/story/covid-19-arua-district-intensifies-screening-at-six-border-entry-points

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4 PREPARATION AND OBJECTIVES OF THE ESMF

4.1 Objective of this ESMF Key objectives of the ESMF are to:

. Enhance positive social and environmental impacts of the project and avoid/minimize or manage any potential adverse impacts. Provide guidance to Ministry of Health (MoH) in developing environmental and social (E&S) instruments in response to COVID-19 situations following national regulations and the World Bank‟s Environmental and Social Safeguards Policies. The instruments will include templates of Environmental and Social Management Plan (ESMP) and Infection Control and Waste Management Plan (ICWMP). The former aims to provide an overarching action plan for the management of environmental, social, health and safety (ESHS) issues associated with the construction and operation of healthcare facilities in response to COVID-19. The latter focuses on proper infection control and healthcare waste management practices during operation of healthcare facilities. The ICWMP is considered part of the ESMP. . Discuss COVID-19 emergency activities as stipulated in the national preparedness and response plan. . Define procedures to assess environmental and social impacts of those activities. . Recommend measures/plans to reduce, mitigate and/or offset adverse impacts.

Project implementation will follow environmental requirements of Government of Uganda and the World Bank environmental and social safeguards policies. The ESMF provides procedures and methodologies for identifying potential environmental and social impacts during project planning, design and implementation and outlines generic management instruments required to effectively address them. Appropriate institutional arrangements towards implementing the ESMF and capacity building efforts required have been provided in the framework. The ESMF also provides guidance in cases where screening indicates that a separate Environmental Impact Assessment (EIA) is required. The ESMF includes an Environmental Management Plan (EMP) for the project‟s implementation, which outlines institutional arrangements necessary for implementation of mitigation and monitoring measures, timeline, capacity building and training measures, and cost estimates for activities under the proposed program.

For Ebola CERC and COVID-19 emergency response, the ESMF does not aim to assess impacts of EVD or COVID- 19 outbreak in general terms but focuses on likely social and environmental impacts of associated emergency response sites/ facilities and operations, as discussed in Chapter 7 (Section 7.4).

4.2 Methodology used to prepare and /or update the ESMF

The ESMF was prepared using the following methodology: a) Document review including the following:

. Uganda Statistical Abstract 2014, . The National Environment Act 1995, . Environment Checklist of the Ministry of Local Government, . World Bank Safeguard Policies, . Approaches to health care waste management health workers guide 2nd Edition (USAID, 2013) b) Stakeholder consultations: Record is provided in Annex 5. c) Update of the ESMF to include COVID-19 CERC was undertaken by Ministry of Health in close collaboration with World Health Organization to provide the CERC Implementation Plan and National/ International Protocols for Management of COVID-19. The update also took cognizance of World Bank‟s guidance on CERC-ESMF

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development following ESF requirements, though this activity is being managed under the E&S Safeguards Policies. It was not possible to undertake Public Stakeholder Consultations given the rapidly evolving COVID-19 situation and the accompanying National IPC guidelines which ban congregations of more than 10 persons. Implementation of CERC involves multi-institutional approach and massive community outreach program which shall be undertaken in a transparent manner and taking into consideration contextual issues and aspects in various communities, with the ultimate objective of IPC.

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5 POLICY, LEGAL AND INSTITUTIONAL FRAMEWORK

In this section the policies, legal and institutional frameworks for environmental management in U ganda are discussed.

5.1 Policy Framework

5.1.1 The National Environment Management Policy, 1994

The overall goal of this policy is the promotion of sustainable economic and social development mindful of the needs of future generations and the EIA is one of the vital tools it considers necessary to ensure environmental quality and resource productivity on a long-term basis. It calls for integration of environmental concerns into development policies, plans and projects at national, district and local levels. The policy requires that projects likely to have significant adverse ecological or social impacts undertake an EIA before their implementation. This is also reaffirmed in the National Environment Act, Cap 153 which makes EIA a requirement for eligible projects (Third Schedule).

Relation to the project: This policy is the foundation of all laws and regulations associated with environmental management in Uganda

5.1.2 The National Health Policy, 1999

The overall objective of health sector policy is to reduce mortality, morbidity and fertility, and the disparities therein. Ensuring access to the minimum health care package is a central strategy to this goal.

Relation to the project: This policy is the foundation of health laws in Uganda

5.1.3 The National Medical Equipment Policy, 2009

The objective of the policy is to ensure equipment and furniture are managed economically, efficiently, effectively and sustainably through guided;

a) acquisition of medical equipment and furniture, b) utilization, regulation and quality assurance of medical equipment and furniture, c) maintenance of medical equipment and furniture, d) monitoring and evaluation of performance of medical equipment and furniture and e) disposal of medical equipment and furniture.

Relation to the project: This policy guides acquisition, utilization, maintenance monitoring and disposal of medical equipment and furniture

5.1.4 National Health Care Waste Management Plan (2009/2010–2011/2012)

The National Health Care Waste Management Plan (NHCWMP) was prepared and disclosed under previous IDA projects to guide healthcare facilities and personnel in safe and proper management of healthcare waste.

In addition to NHCWMP, MoH developed the following documents to guide proper healthcare waste management and infection control:

. Approaches to Health Care Waste Management (HCWM), Health Workers Guide, Second Edition (2013);

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. Uganda National Infection Prevention and Control Guidelines (December 2013); . National Policy on Injection Safety and Health Care Waste Management (2014).

Key considerations in managing EVD health-care waste entail having a detailed HCW management plan during the design of Ebola treatment facilities. There are WHO SOPs for management of EVD-related medical waste (see Annex 14) and therefore what is needed is training local healthcare staff and availing the necessary resources. It is also noted that all major hospitals in Uganda have onsite incinerators for healthcare waste incineration.

Relation to the project: The NHCWMP and other guidebooks listed above were prepared to enhance capacity of healthcare facilities and personnel in safe and proper management of healthcare waste. It is noted that those guidelines are not specific to EVD medical waste therefore World Health Organisation (WHO) guide for managing EVD medical waste is provided in Annex 14.

5.1.5 National Technical Guidelines for Integrated Disease Surveillance and Response, 2012

These guidelines aim at addressing how to implement national emergency response as well as international health regulations requirements for disease surveillance and response. The guidelines reflect national priorities, set policies and standards. The guidelines are intended for use as:

. A general reference for surveillance activities at all levels in Uganda . A set of definitions for threshold levels that trigger some action for responding to specific diseases . A resource for developing training, supervision and evaluation of surveillance activities . A guide for improving early detection, preparedness for outbreak response and case management.

Relation to the project: The guidelines list EVD as one of the communicable diseases to continually undertake surveillance for.

5.2 Legal Framework 5.2.1 Constitution of the Republic of Uganda, 1995

The 1995 Uganda Constitution provides that every person has a right to own property [Section 26.1] and that no person shall be deprived of property or any interest in or right over property without payment of fair and adequate compensation. The same constitution gives government powers to acquire land (compulsory acquisition) in public interest [Article 273(a)]. The Constitution [Chapter 3, Article 17J] entrusts Government with the duty of ensuring that Ugandans enjoy a healthy environment.

Relation to the project: The Constitution is the cardinal law onto which the National Environment Act Cap 153 is based.

5.2.2 National Environment Act, Cap 153

The National Environment Act (Chapter 153 of Laws of Uganda) establishes and defines functions of NEMA as a body responsible for management, monitoring and supervision of all environmental conservation activities (Section 4). This act provides for various strategies and tools for environment management, which also includes the EIA (Section 19) for projects likely to have significant environmental impacts. The Act also mandates NEMA with a leading role to review environmental impact statements. NEMA sets multimedia environmental standards (Sections 24-32) to prevent contamination of air, water and soil resources. The Act also mandates NEMA with responsibility for in-situ and ex-situ conservation of biological fauna and flora resources either on land or in water (Sections 42 and 43). Section 48 empowers NEMA, district environment committees and local environment committees to be responsible for monitoring of local land-use plans, which should be in conformity with national land-use plan. Third

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Schedule of National Environment Act (Cap 153) does not specifically list healthcare facilities under scheduled projects, nonetheless, two sections thereof related to function or waste management mean that these facilities are not exonerated from the general EIA process. Section 1 General (a) an activity out of character with its surroundings; Section 12 on the Schedule requires that projects below should undertake ESIA: i) sites solid waste disposal ii) sites for hazardous waste disposal iii) sewage disposal iv) atmospheric emissions v) offensive odors

Relation to the project: This Act formed the basis for enactment of the Environmental Impact Assessment Guidelines, 1997 and Environmental Impact Assessment Regulations, 1998 which together prescribe the EIA process in Uganda.

5.2.3 Land Act, Cap 227

The Land Act provides for tenure, ownership and management of land. Land is to be used in compliance with relevant national laws such as listed in Section 43 including the Water Act and National Environment Act. Section 44 reiterates the constitutional mandate for government or a local government to protect environmentally-sensitive areas for the common good of the people in Uganda. The Act describes land ownership types of tenure and echoes requirement of the Constitution to equitably compensate persons losing land to a given development.

Relation to the project: This Act guides about landownership under various tenure systems, namely: mailo, lease, customary and freehold. It also the legal instrument that governs any land acquisition process, compensation and conflict redress between a rightful owner and encroachers.

5.2.4 Local Governments Act, Cap 243

This Act provides for decentralized governance and devolution of central government functions, powers and services to local governments that have own political and administrative set-ups. According to Section 9 of the Act, a local government is the highest political and administrative authority in its area of jurisdiction and shall exercise both legislative and executive powers in accordance with the Constitution.

Relation to the project: This Act means that local governments have administrative authority over projects implemented in areas of their jurisdiction.

5.2.5 Public Health Act, Cap 281

Section 105 of the Public Health Act, 1964 requires local authorities to take measures to prevent pollution of public water resources. This Act aims at avoiding pollution of environmental resources that support health and livelihoods of communities.

Relation to the project: In respect to this project this Act best relates to management of construction waste and healthcare waste in the post-construction phase.

5.2.6 National Environment (Standards for Discharge of Effluent into Water or on Land) Regulations, 1999

Section 6 (2) details maximum permissible limits for 54 regulated contaminants which must not be exceeded before effluent is discharged into water or on land. For this project, this standard is applicable to sewage disposal from healthcare facilities.

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Relation to the project: In respect to this project this Act best relates to management of construction waste and healthcare waste in the post-construction phase.

5.2.7 National Environment (Waste Management) Regulations, 1999

These regulations require waste disposal in a way that would not contaminate water, soil, and air or impact public health. According to the regulations, waste haulage and disposal should be done by licensed entities.

Relation to the project: Same as for Section 5.2.6

5.2.10 Employment Act, 2006

Employment Act, 2006 repeals Employment Act (Cap 219) enacted in 2000. This Act is the principal legislation that seeks to harmonize relationships between employees and employers, protect workers interests and welfare and safeguard their occupational health and safety through:

. Prohibiting forced labor, discrimination and sexual harassment at workplaces (Part II; Part IV). . Providing for labor inspection by the relevant ministry (Part III). . Stipulating rights and duties in employment (weekly rest, working hours, annual leave, maternity and paternity leaves, sick pay, etc. (Part VI). . Continuity of employment (continuous service, seasonal employment, etc. (Part VIII).

Relation to the project: In the construction phase this Act guides the relationship between contractors and construction workers while in the operation phase it manages the legal relationship between medical facilities and healthcare workers.

5.2.12 Occupational Safety and Health Act (2006)

The Act replaces the Factories Act (1964). It departs from the original listing of “don‟ts” and adopts a scientific approach in which technical measures required for protection of workers are prescribed, hence taking on a “preventive approach”. The Act provides for prevention and protection of persons at all workplaces from injuries, diseases, death and damage to property. It covers not just the “factory” (as did the Factories Act) but also any workplace where persons are employed and its provisions extend not just to employees but to any other persons that may be legitimately present in a workplace and are at risk of injury or disease. Employers must protect workers from adverse weather and provide clean and healthy work environment, sanitary conveniences and protective gear.

Relation to the project: For this project this Act is applicable in relation to protection of health workers (and medical waste collectors) against secondary injuries during execution of their work.

5.3 Institutional Framework 5.3.1 National Environment Management Authority (NEMA)

NEMA is the principal agency responsible for coordination, monitoring and supervision of environmental conservation activities. NEMA is under the Ministry of Water and Environment (MoWE) but has a cross-sectoral and regulatory mandate for overall environmental management in the country including overseeing the conduct of EIAs through issuance of guidelines, regulations and registration of practitioners. It reviews and approves environmental assessments in consultation with any relevant lead agencies. It undertakes follow up monitoring to ensure implementation of mitigation measures for projects. NEMA works with District Environment Officers and local

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environment committees at local government levels who also undertake inspection, monitoring and enforce compliance on its behalf. In Government ministries, NEMA works with Environmental Liaison Units to ensure incorporation of environmental issues in their activities, policies and programs.

Relation to the project: NEMA is the national agency responsible for setting environmental laws, regulations, managing and monitoring environmental performance in Uganda.

5.3.2 Ministry of Health (MoH)

This project will be executed by MoH which is to undertake policy formulation, quality assurance, coordination, monitoring and evaluation of health service delivery in Uganda.

Relation to the project: Ministry of Health as a project developer responsible for its implementation.

5.3.3 Ministry of Gender, Labor & Social Development

This ministry sets policy direction and monitoring functions related to labor, gender and general social development. The OHS unit in the ministry is responsible for inspection and mentoring of occupational safety in workplaces and this could be during project construction and operation of the healthcare facilities.

Relation to the project: The OHS in Ministry of Gender, Labor and Social Development is mandated to supervise all workplaces for safety of workers both during construction and operation.

5.3.4 District Local Administration Structures

The proposed project is within a number of jurisdictions of a number of Districts headed by a Local Council 5 (LC5) Chairman and Chief Administration Officer (CAO) who are the political head and technical head respectively. Various district offices whose functions would be relevant to the project include offices of Natural Resources/Environment, District Health Officer, District health inspector/educator, District Planner, Community Development Officer, , Wetlands Officer, Land Office, District Water Officer, Town Council and District Engineer. Equally important are village-level local council administration (LC I and LC III). Leaders at these levels of local administration are closer to residents and therefore important in effective community mobilization, sensitization and dispute resolution. The District and Local/Health Unit Health Teams will also be involved in project implementation.

Relation to the project: Local governments have administrative authority over projects implemented in respective areas of their jurisdiction and are expected to participate in supervision and monitoring project implementation and operation. In case of an Ebola outbreak, assistance of local governments would be essential in identifying location of isolation areas, coordination and communication between the Public Health Emergency Operations Centre (PHEOC), health workers in Ebola Treatment Units (ETUs) and at Points of Entry (PoEs) to enable quick identification, notification, transfer and management of EVD patients or suspected victims, including surveillance. 6 THE WORLD BANK’S SAFEGUARD POLICIES

6.1 Operational Policies

The World Bank‟s Environmental and Social Safeguards policies are designed to help ensure that programs proposed for Bank financing are environmentally and socially sustainable, and thus improve decision-making. These operational policies are outlined below and ones to be triggered by the project, EVD or COVID-19 emergency operations are indicated:

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Table 6: World Bank environmental and social safeguards showing ones to be triggered Safeguard Policies Triggered? Reason Yes No x Under Pillar: 1 “Case Management”, COVID-19 OP 4.01 Environmental emergency operations will entail facilitating set up Assessment (and decommissioning) of waste disposal systems (waste pits, incinerators, soak away pits), some of which (e.g. incinerators) will pose E&S risks and impacts and thus require environmental assessment as per this policy. However, the CERC activities shall as much as possible make use of existing facilities.

Interventions under the EVD and URMCHIP projects involve improvement in provision of health services and construction works. Civil works will pose health and safety risks besides generating construction waste. Therefore OP/BP 4.01 is triggered. Emergency operations will utilise resources and generate waste, some of which would be hazardous waste requiring appropriate waste management protocols including prevention (of waste generation) and resource efficiency. Healthcare workers involved in EVD, COVID-19 planned emergency response programs and activities of URMCHIP will require safe working conditions that protect them from infections while on duty. The World Bank EHS Guidelines shall be followed to manage Health and Safety of COVID- 19, covering both Public and Occupational aspects.

Since the participating health facilities are not yet determined or known, Environmental and Social Management Framework has been prepared to guide management of environmental and social aspects. Once the specific sites and respective activities have been identified, ESIA shall be undertaken and ESMPs developed before start of any works.

Healthcare workers involved in EVD, COVID-19 planned emergency response programs and activities of URMCHIP will require safe working conditions that protect them from infections while on duty. COVID and EVD emergency operations will necessitate measures to adequately protect health and safety of communities concerned. OP 4.04 Natural Habitats x The project will have no adverse impact on natural habitats. OP 4.09 Pest Management x The project will not entail use of pesticides.

OP 4.11 Physical Cultural x This is triggered because project investments Resources involve civil works and may affect physical cultural resources or chance finds. At this stage, the project ESMF will includes provisions for chance finds management. The respective ESIAs to be

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Safeguard Policies Triggered? Reason Yes No undertaken (compilation of Project Briefs & ESMPs) will include PCRs investigation, assessment and management measures. OP 4.12 Involuntary Resettlement, x A resettlement policy framework (RPF) has been prepared separately for this project. The RPF will guide landownership relationships between the healthcare facilities any person who lays claim to their land. The project interventions under Component 2 will be undertaken in existing health facilities and therefore there is likely no land- take/acquisition or loss of livelihoods. However, since the specific facilities (hospitals and HCIVs) and scope of activities are not known at this point, additional land may be required in cases where expansion of the health facility may be required. RPF has been prepared in a consultative manner and disclosed both in-country by the client and at Infoshop by IDA before project appraisal. OP 4.10 Indigenous People x This policy will be triggered because some project healthcare facilities will be in indigenous people areas: such as Ik people in Kaabong District, and Batwa in Districts of Kisoro, Bundibugyo, Kasese and Kanungu. Therefore, an Indigenous Peoples Planning Framework (IPPF) has been prepared for Batwa while an Indigenous Peoples Action Plan (IPAP) will be written for Ik people. OP 4.36 Forests x The project is not expected to affect the management of forests and neither will it support forest nor logging operations. OP 4.37 Safety of Dams x The project will not support or depend on dams. OP 7.50 Projects on International x This does not apply to the project. Waterways OP 7.60 Projects in Disputed x The project will not be implemented in disputed Areas. areas.

6.2 World Bank Group Guidelines

The World Bank has several guidelines below, many of which are applicable to various components of the proposed project namely: i) Air emissions from onsite waste combustion units (“incinerators”) ii) Hazardous waste management iii) Noise iv) Occupational health and safety (against biological and radiological hazards). v) Community health and safety including traffic safety such as during project construction or disease prevention (where incinerators emission waft into and affect not only local communities but also patients visiting healthcare facilities). vi) Construction and decommissioning.

While most of above WBG guidelines apply to the proposed project in one way or the other, in sections below are discussed five environmental, health and safety (EHS) guidelines, namely:

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. EHS Guidelines - AIR EMISSIONS AND AMBIENT AIR QUALITY . EHS Guidelines - WASTE MANAGEMENT . EHS Guidelines - HEALTH CARE FACILITIES . EHS Guidelines - HAZARDOUS MATERIALS MANAGEMENT . EHS Guidelines - CONSTRUCTION AND DECOMMISSIONING

6.2.1 WBG EHS Guidelines: “Air emissions and ambient air quality” a) General approach

These guidelines require projects with “significant”17 sources of air emissions, and potential for significant impacts to ambient air quality to prevent or minimize impacts by ensuring that emissions do not result in pollutant concentrations that reach or exceed relevant ambient quality guidelines and standards by applying national legislated standards (or in their absence, the current WHO Air Quality Guidelines, or other internationally recognized sources). Uganda currently has (draft) national air quality standards applicable to this project, specifically incinerator emissions. The standards however make no mention of dioxins which are potent cancer-inducing, expected in incineration emissions.

In these guidelines “significant” refers to sources which can contribute a net emissions increase of one or more of the following pollutants within a given airshed:

. Particulate matter of size 10 microns (PM10): 50 tons per year (tpy); . Oxides of nitrogen (NOx): 500 tpy; . Sulphur dioxide (SO2): 500 tpy; or as established through national legislation; . Equivalent heat input of 50 MWth or greater.

Going by this classification, all onsite incineration units at existing healthcare facilities are “non-significant” sources since no unit at any of the project facilities had capacity to generate the foregoing levels of air pollutants. Two national documents18 on healthcare waste indicate that healthcare facilities, depending on their service level, generate the following average quantities of medical waste:

. Hospital: 0.1 kg/bed/day (excluding pathological waste) . Health center 4 (HC IV): 1.5 kg/day . Health center 3 (HC III): 0.6 kg/day . Health center 2 (HC II): 0.5 kg/day

The fact that onsite incineration units burn small waste volumes and generate low levels of emissions could be the reason such “non-significant” units are not provided with (and probably do not require) emissions control.

Incineration emissions from healthcare facilities may contain particulate matter, heavy metals, dioxins, furans, sulfurdioxide and hydrochloric acid. Of key concern are dioxins which are cancer-inducing compounds19. The temperatures needed to breakdown dioxin are typically not reached when burning waste in open air (200-400°C) causing high dioxin emissions. Dioxin can only be destroyed above 850°C, otherwise it remains in atmosphere emissions or in incineration ash where it can leach into groundwater when rain falls on ash piles.

17 Significant sources of point and fugitive emissions in these (WBG) guidelines are considered to be general sources which can contribute a net emissions increase of one or more of the following pollutants within a given airshed: PM10: 50 tons per year (tpy); NOx: 500 tpy; SO2: 500 tpy; or as established through national legislation; and combustion sources with an equivalent heat input of 50 MWth or greater. The significance of emissions of inorganic and organic pollutants should be established on a project-specific basis taking into account toxic and other properties of the pollutant. 18 “National Healthcare Waste management Plan (2007/8-2009-2010)” and “Improvement of Healthcare Waste Management in Uganda (July 2005, Updated Mar 2009) by Carl Bro. 19 Note that WBG EHS Guidelines: “Healthcare facilities” give air emission levels for hospital waste incineration facilities.

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b) Implication for this project

The guidelines discourage open-burning of solid wastes, whether hazardous or non-hazardous, is not considered good practice and should be avoided, as the generation of polluting emissions from this type of source cannot be controlled. While small onsite incineration units handling minimal healthcare waste volumes might not require emission control according to these Guidelines, the management including disposal of healthcare waste has become an issue of growing concern in many places in Uganda. Infectious medical waste has been dumped indiscriminately, burned uncontrollably and buried irresponsibly posing considerable public health risk.

Component 2 under “Improved quality of care and supervision” will develop various service standards/protocols on health care waste (HCWM) alongside others such as for ones for maternal and perinatal death audits. It is hoped that these standards will sustain improvement in healthcare waste management.

6.2.2 WBG EHS Guidelines: “Waste management” a) General approach

Regarding the proposed project, this section considers only construction waste originating from repairs, renovations and building of healthcare facilities. The guidelines advocate for waste management planning where waste should be characterized according to composition, source, types, and generation rates.

These guidelines call for implementation of a waste management hierarchy that comprises prevention, recycling/reuse; treatment and disposal. The guidelines require segregation of conventional waste from hazardous waste streams. Examples of hazardous construction waste are waste oil from vehicles and machinery paint waste, thinners and concrete wash water (e.g. from cleaning concrete mixers). d) Implication for this project

Improper management of construction waste would pose environmental and public health impacts. Contractors will have a contractual obligation to ensure proper construction waste management. To this end, guidelines provided in Annex 4 (Clauses for Construction Work Contracts on Environmental Compliance) and Annex 12 (Code of Practice for Construction Workers) should be utilized as vital guiding documents.

6.2.3 WBG EHS Guidelines: “Healthcare facilities” a) Applicability

The EHS Guidelines for healthcare facilities include information relevant to management of EHS issues associated with healthcare facilities (HCF) which includes a diverse range of facilities and activities involving general hospitals and small inpatient primary care hospitals, as well as outpatient facilities. Ancillary facilities may include medical laboratories and mortuary centers.

These guidelines are applicable for planning new HCFs or renovation of existing facilities.

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b) Healthcare facility design considerations20

These guidelines advise that design and functional layout of HCFs should ensure the following:

. Separation of clean / sterilized and dirty / contaminated materials and people flows; . Development and inclusion of adequate disinfection / sterilization procedures and facilities; . Adequate space for the storage of recyclable materials (e.g. cardboard and plastic) for pickup; . Ventilation systems that provide isolation and protection from airborne infections; . Design of water systems to provide adequate supplies of potable water to reduce risks of exposure waterborne pathogens; . Provision of hazardous material and waste storage and handling areas; . Selection of easily cleaned building materials that do not support microbiological growth, are slip-resistant, non- toxic, and non-allergenic, and do not include volatile organic compound (VOC)-emitting paints and sealants. c) Waste management

Waste from health care facilities (HCF) can be divided into two groups:

. General waste similar in composition to domestic waste, generated during administrative, housekeeping, and maintenance functions. . Specific categories of hazardous healthcare waste.

Health care facilities should establish, operate and maintain a health care waste management system (HWMS) adequate for the scale and type of activities and identified hazards but entailing: i) Waste minimization, reuse, and recycling ii) Waste segregation at the point of generation, iii) On-site handling, collection, transport and storage based on safe practices below

. Seal and replace waste bags and containers when they are approximately three quarters full. Full bags and containers should be replaced immediately. . Identify and label waste bags and containers properly prior to removal. . Transport waste to storage areas on designated trolleys / carts, which should be cleaned and disinfected regularly. . Waste storage areas should be located within the facility and sized to the quantities of waste generated. . Unless refrigerated storage is possible, storage times between generation and treatment of waste should not exceed (in Warm climate) 48 hours during cool season, 24 hours during hot season. . Store radioactive waste in containers to limit dispersion, and secure behind lead shields. . Packaging containers for sharps should be puncture-proof.

These guidelines recognize incineration as a key source of air emission at healthcare facilities and pollutants emitted from incineration include: i) Heavy metals ii) Organics in flue gas iii) Various organic compounds (dioxins and furans) iv) Hydrogen chloride (HCl) and fluorides and potentially other halogens-hydrides (e.g. bromine and iodine)

20 Internationally recognized guidelines for design and construction of hospitals and HCFs include American Institute of Architects (AIA) and the Facility Guidelines Institute (FGI), the American Society for Healthcare Engineering (ASHE) of the American Hospital Association (AHA), and the Green Guide for Healthcare.

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v) Typical combustion products such as sulfur oxides (SOx), nitrogen oxides (NOx), volatile organic compounds, monoxide (CO), carbon dioxide (CO2), and nitrous oxide (N2O). vi) Incineration residues such as fly ash and bottom ash may contain high concentrations of persistent organic pollutants (POPs).

For being ineffective in regard to emissions control, these WBG Guidelines caution against use of single-chamber and brick incinerators should be used only as a last resort option. The Guidelines advise against mixing domestic and hazardous waste. Waste should be segregated at point of generation and non-hazardous waste, such as paper and cardboard, glass, aluminum and plastic, should be collected separately for possible recycling. Food waste should be segregated and composted. Infectious and / or hazardous wastes should be identified and segregated according to its category using a color-coded system. If different types of waste are mixed accidentally, waste should be treated as hazardous. d) Occupational health and safety

HCF health and safety hazards may affect healthcare providers, cleaning and maintenance personnel, and workers involved in waste management handling, treatment and disposal. Typical hazards which should be prevented with proper safety gear and practices include:

. Exposure to infections and diseases (blood-borne pathogens, and other potential infectious materials (OPIM)21 . Exposure to hazardous materials / waste . Fire safety . Exposure to radiation

Occupational radiation exposure may result from equipment emitting X-rays and gamma rays (e.g. CT scanners), radiotherapy machines, and equipment for nuclear medicine activities. HCF operators should develop a comprehensive plan to control radiation exposure in consultation with the affected workforce. This plan should be refined and revised as soon as practicable on the basis of assessments of actual radiation exposure conditions, and radiation control measures should be designed and implemented accordingly. e) Air emission levels for hospital waste incineration facilities

WBG Guidelines advise the following emission levels of healthcare waste incinerators.

Table 7: Air emission levels for hospital waste incineration facilities (WBG Guidelines) Pollutant Unit Guideline value Total Particulate matter (PM) mg/Nm3 10 Hydrogen Chloride (HCl) mg/Nm3 10 Total organic carbon (TOC) mg/Nm3 10 Hydrogen Fluoride (HF) mg/Nm3 1 Sulfur dioxide (SO2) mg/Nm3 50 Carbon Monoxide (CO) mg/Nm3 50 NOX mg/Nm3 200-400a Mercury (Hg) mg/Nm3 0.05 Sb, As, Pb, Cr, Co, Cu, Mn, Ni, and V mg/Nm3 0.05 Polychlorinated dibenzodioxin and ng/Nm3TEQ 0.1

21 According to US Occupational Safety and Health Administration (OSHA), blood-borne pathogens are pathogenic microorganisms that are present in human blood and can cause disease in humans, including human immunodeficiency virus (HIV), hepatitis B virus (HIB), and hepatitis C virus (HCV). Other potentially infectious materials (OPIM) refers to (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV- containing cell or tissue cultures, organ cultures, and HIV- or hepatitis B virus (HBV) -containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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Pollutant Unit Guideline value dibenzofuran (PCDD/F) Notes: a. 200 mg/m3 for new plants or for existing incinerators with a nominal capacity exceeding 6 tonnes per hour; 400 mg/m3 for existing incinerators with a nominal capacity of 6 tonnes per hour or less. b. Oxygen level for incinerators is 7 percent.

The implications for the project:

During project implementation, healthcare facilities will apply the National Health Care Waste Management procedures which inherently have provisions designed to satisfy WB EHS Guidelines discussed in this section.

6.2.4 WBG EHS Guidelines: “Hazardous materials management” a) Application and approach

These guidelines apply to projects that use, store, or handle any quantity of hazardous materials (Hazmats), defined as materials that represent a risk to human health, property, or the environment due to their physical or chemical characteristics. Hazmats can be classified according to the hazard as explosives; compressed gases, including toxic or flammable gases; flammable liquids; flammable solids; oxidizing substances; toxic materials; radioactive material; and corrosive substances. b) General hazardous materials management

Facilities which manufacture, handle, use, or store hazardous materials should establish management programs that are commensurate with the potential risks present. The main objectives of projects involving hazardous materials should be the protection of the workforce and the prevention and control of releases and accidents. These objectives should be addressed by integrating prevention and control measures, management actions, and procedures into day- to-day business activities.

6.2.5 WBG EHS Guidelines: “Construction and decommissioning”

These provide guidance, specific guidance on prevention and control of community health and safety impacts that may occur during new project development or due to expansion or modification of existing facilities. By thematic categories, they address three major aspects (environment, OHS and community health and safety) below.

i) Environment:

. Noise and Vibration: During construction and decommissioning activities, noise and vibration may be caused by the operation of pile drivers, earth moving and excavation equipment, concrete mixers, cranes and the transportation of equipment, materials and people. . Air Quality: Project will involve demolition of walls inside existing healthcare facilities and this could generate fugitive dust affecting adjoining rooms or service areas. A secondary source of emissions may include exhaust from diesel engines of earth moving equipment, as well as from open burning of construction and demolition waste on-site. . Solid Waste: During project implementation, non-hazardous solid waste generated at construction sites would include, scrap wood, glass cullet and metal and demolition rubble. . Hazardous Materials: Asbestos might be encountered where entire buildings will be demolished and rebuilt. In case of this encounter, NEMA shall provide written guidance (work procedure) on handling and disposal of asbestos materials.

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ii) Occupational Health and Safety

Likely OHS risks during proposed renovation of HCFs include over-exertion, slips and falls, work at heights, hotworks (welding), electrocution, being struck by objects, injury by moving machinery and dust from demolition activities.

iii) Community Health and Safety:

The guidelines recommend implementation of risk management strategies to protect general community from physical, chemical, or other hazards associated with sites under construction and decommissioning. Key areas to consider are: . General site hazards: where renovation activities can injure people in or near buildings under renovation or construction. . Disease Prevention: ensuring that risk of disease from construction-related activities (e.g. from water ponding). . Traffic Safety: Construction activities may result in a significant increase in movement of heavy vehicles for the transport of construction materials and equipment increasing the risk of traffic- related accidents and injuries to workers and local communities.

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7 GENERIC ENVIRONMENTAL AND SOCIAL IMPACTS 7.1 Introduction

The interventions under the project involve improvement in provision of health services, handling of medical products. Generally, these activities may result in positive and negative potential impacts as discussed in this chapter. Potential environmental and social impacts can be adequately managed by integrating environmental and social due diligence into the sub-project cycle. Since the exact participating facilities and their location are not yet known, and it is not clear whether or not the project could lead to acquisition of additional land and or loss of livelihoods of some individuals or communities, Environmental and Social Management Framework (ESMF) and a Resettlement Policy Framework (RPF) have been prepared to guide handling of project environmental and social aspects during implementation. An indigenous peoples policy framework (IPPF) has also been prepared for this project.

In addition to the National Health Care Waste Management Plan (2009/2010 – 2011/2012) prepared and disclosed under a previous IDA project, the MoH has the following documents on health care waste management and infection control: Approaches to Health Care Waste Management, Health Workers Guide, Second Edition (2013); Uganda National Infection Prevention and Control Guidelines (Dec 2013); and the National Policy on Injection Safety and Health Care Waste Management (2014). These documents shall guide management of HCW under the project.

Environmental compliance is the responsibility of the Environmental Health Division (EHD) of the MoH which is charged with coordination of health care waste management activities under the overall policy guidance of the National Environment Management Authority (NEMA). Functionality and capacity of EHD to handle environmental and social Safeguards requirements has been assessed during preparation of the ESMF and measures suggested to address gaps identified. The key action includes MoH to hire Environmental Specialist and undertake safeguards training for key project personnel at the start of project implementation.

Possible impacts of the project are discussed in sections below.

7.2 Generic Construction-Phase Impacts Potential construction phase impacts are discussed in sections below.

7.2.1 Positive social impacts 7.2.1.1 Income to material/ equipment suppliers and contractors

Proposed renovation of and small scale construction/civil works at health centers will necessitate procurement of equipment, construction materials and service, providing income to suppliers and contractors. This is a positive but short-term and reversible impact. Considering that construction labor would be local or national but medical equipment procured internationally, this impact has local, national and international spatial extent.

This impact could be enhanced by measures proposed below.

Enhancement measure

Earth materials needed for construction e.g. murram, aggregate (stone, sand) are obtained from legitimate/ licensed quarry operations. Conscious or unwitting purchase of these materials from unlicensed operations indirectly supports, encourages and promotes environmental degradation at illegal quarry sites and can cause medium- to long-term negative impacts, that also pose reputational risks to both GoU and IDA. It should therefore be a contractual obligation for contractors to procure construction materials from legitimate or licensed sources (as advised by local authorities).

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7.2.2 Negative social impacts 7.2.2.1 Occupational health safety (OHS) Risks for Contractors

Impact identification

At all sites, renovation works may have the following occupational health and safety risks with potential to cause serious injuries to workers:

. Exposure to asbestos containing materials. . Burns from welding (hot works) . Falls from working at heights or wet surfaces . Electrocution . Noise and body vibration during demolition . Injury from falling or flying debris when demolishing walls . Transient pools of water that may become breeding ground for mosquitoes

Impact evaluation

OHS impacts could potentially occur at every facility under renovation and while some accidents could be minor and not life threatening, others can be grave leading to permanent disability or loss of life of construction workers. Ugandan and WBG Guidelines require that workers exposed to health and safety risks are given proper personal protection Equipment (PPE). Related OHS safeguards are comprised in (Uganda‟s) Occupational Safety & Health Act (2006) and Employment Act, 2006.

Impact severity

Duration of the impact will be short-term occurring only during the construction phase. Extent of the impact will be local or national depending on origin of construction workers. The likelihood of the impact occurring is medium considering the usually low level of safety at construction sites in Uganda. Significance of this impact is therefore predicted to be high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation

. Contractors should provide all workers with requisite protective gear (as a minimum as set out in Table 8). . Contractor should provide onsite toilet and washing water for workers. . The water storage tank should be covered and properly managed to minimise mosquitoes breeding.

Table 8: Personal protective equipment according to hazard Objective Workplace hazards PPE Eye and face protection Flying particles Safety glasses Head protection Falling objects, inadequate Plastic hard hats with top and side height clearance, and overhead power cords impact protection

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Objective Workplace hazards PPE Hearing protection Noise Ear plugs or muffs Foot protection Falling or rolling objects, Safety shoes and boots pointed objects Hand protection Hazardous materials, cuts Gloves made of rubber or or lacerations synthetic materials Respiratory protection Dust Facemasks filters for dust removal Body/leg protection Hazardous materials, biological agents, cuttings Overalls and lacerations. Working on slippery, wet floors Rubber boots Protection against falls Fatal falls from working at heights Safety latches (fall arrestors)

Impact management: Project supervising engineers (of MoH) should inspect contractors‟ compliance with safety precautions during construction.

7.2.2.2 Injury to patients or healthcare staff by construction activities

Impact identification

Renovation works would not close off visits to healthcare facilities by patients neither would inpatients be required to vacate facilities being worked on. For facilities where renovation entails modification of internal built environment, it is planned to temporarily relocate patients and medical services to adjoining rooms to allow demolition and reconstruction. Construction work undertaken in the same buildings having patients has potential to cause injuries to patients or health workers.

Impact evaluation

Impact on patients and health workers could be due to falling debris or tripping on strewn demolition rubble. These effects might either be minor or fatal if for example fatal falls were suffered by geriatric people or pregnant women.

Construction noise and vibration from manual or motorized demolition activities could affect patients and health workers especially those with heart disorders.

Impact severity

This impact will likely occur at every facility under renovation. Duration of the impact will be short-term occurring only during the construction phase. Extent of this impact will be local limited to buildings renovated (when at the same time occupied by patients or health workers). However secondary effects of this impact could be of wider spatial extent affecting family and dependants of injured persons. Some injuries or loss of life are irreversible. The likelihood of the impact occurring is medium (or high) considering the usually low level of safety at most construction sites in Uganda. Significance of this impact is therefore predicted to be high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

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Impact mitigation

. Contractors should cordon off areas under construction and regulate access to active sites by non- construction personnel at all times. . Ensure good housekeeping and clean operations always immediately removing rubble strewn outside construction areas, and ensuring proper site layout in materials storage including designating escape routes and fire assembly point. . Construction workers should be aware of the sensitive nature of workplaces they are operating in and advised to limit verbal noise or other forms of noise. For example, metallic objects or tools can be passed on to a colleague below to be quietly laid down instead of dropping them on cement/ concrete floors with loud bangs. . The contractor should ensure that noise levels emanating from machinery, vehicles and noisy construction activities are kept at a minimum for the safety, health and protection of people in buildings being renovated. All buildings under renovation shall be evacuated and re-occupied after completion of civil works. . Contractors should use screens or nets to avoid flying debris, especially while working at heights.

Impact management

Besides supervision by MoH engineers, contractors‟ contracts can have a clause authorizing a senior healthcare administrator / superintendent at each facility to advise contractors against excessive noise when s(he) notices it.

Wherever space is available, instead of moving patients and service areas to rooms immediately adjoining construction areas, the ideal option should be to use free areas safely distant from construction effects. A grievance mechanism to address complaints from community shall be in place.

7.2.2.3 Traffic accidents

Impact identification

Construction activities may result in a significant increase in number of heavy vehicles during transport of construction materials and equipment, increasing community risk of traffic-related accidents or injuries to workers.

Impact evaluation

Traffic accidents would be a significant social impact and especially likely to involve children, women (who commonly cross roads slower than men), disabled and elderly people.

Impact severity

Impact duration will be short-term occurring only during the construction phase. Extent of this impact will be on all roads plied by project vehicles. The likelihood of the impact occurring is high when control measures are not instituted. The social cost and significance of this impact is high especially if it involved loss of human life which is also irreversible.

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Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation a) Adopt best transport safety practices with the goal of preventing traffic accidents and minimizing injuries suffered by project personnel and the public, as follows:

. Emphasizing safety aspects among project drivers. Specifically ensure drivers respect speed limits through built areas and urban centers. . Adopting limits for trip duration and arranging driver rosters to avoid overtiredness . Avoiding dangerous routes and times of day to reduce the risk of accidents . Position traffic guides at children crossings to control driver speeds. . Employ safe traffic control measures, including road signs and flag persons to warn of dangerous conditions and children crossings. b) Ensure contractors regularly maintain vehicles to minimize potentially serious accidents such as those caused by brake failure commonly associated with loaded construction trucks.

Impact management i) Ensure contractors compile a list of scheduled service schedules of all equipment deployed on site. ii) Pedestrian interaction with construction vehicles can be minimized by:

. Collaboration with local communities and responsible authorities (e.g. police) to improve signage, visibility and overall safety of roads particularly along stretches located near schools or through trading centers. Collaborating with local communities on education about traffic and pedestrian safety (e.g. one road safety campaign at a nearby school once a month). . Using locally sourced materials, whenever possible, to minimize transport distances. . Wherever they would be necessary, encourage contractors to locate associated facilities such as worker camps close to project sites.

A grievance mechanism to address complaints from community shall be instituted.

7.2.2.4 Temporary disruption of healthcare services

Impact identification

Since facilities under renovation would not be closed, modifications of buildings in which medical services are provided may entail moving patients or equipment from one area or room to another. This may cause temporary disruption in delivery of health services to patients at facilities under renovation.

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Impact evaluation

Temporary rearrangement of service areas can have the undesirable consequence of slowing down emergency services or cause inability among health workers to efficiently offer necessary treatment for visiting patients. Movement of equipment may cause their damage.

Impact severity

This impact is short-term but can have long-term and irreversible impacts (such as where human life is lost). Extent of this impact will be mostly local to facilities under renovation although, due to the disturbance, some patients might choose to transfer to alternative healthcare facilities, leading to their congestion.

The impact will potentially occur at every facility in this project. Likelihood of the impact occurring is high and significance is therefore predicted to be medium-high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high  Low- Medium Low Very- Low

Impact mitigation

Plan pre-construction activities early to identify suitable rooms or adjoining buildings into which patients or service areas can be relocated with minimal inconvenience, especially to patients under intensive care. Advance relocation information should be shared with the affected patients for their planning mental preparedness.

Impact management

Contractors should work closely and harmoniously with healthcare facility administrators to find practical ways to minimize social cost of temporary disruption of services. A grievance mechanism to address complaints from community shall be in place.

7.2.2.5 Social misdemeanor by construction workers

While most workers may originate from the local community where they have families, there might be others from distant places and working away from their families. Contractors might be lionized as being wealthy by local people especially for HCFs in rural settings or trading centers. With some disposable income to spend, this might induce illicit sexual relationships, with attendant risk for spread of HIV/AIDS. Impact evaluation

Irresponsible sexual relationships in project communities can break families and heighten risk of defilement and contracting HIV/AIDS.

Impact severity

Illicit sexual relationships can be short-term but have long-term and irreversible effects (HIV/AIDS, pregnancy, etc). If this impact occurred, extent of disease spread would be local or national depending on origin and next destination of

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infected persons. The impact will potentially occur at every facility in this project. Likelihood of the impact occurring is high if contractors do not adequately sensitize workers about responsible and safe behavior. Although it is a cumulative impact, its significance is predicted to be high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation

. The Contractors shall be required to put in place and enforce a Code of Conduct for workers (see example in Annex 12). . As a contractual obligation, contractors should be required to have an HIV/AIDS policy and a framework (responsible staff, action plan, etc) to implement during project execution. . All construction workers should be orientated and sensitized about responsible sexual behavior in project communities.

Impact management

Where a contractor has a centralized camp for construction workers, posters about HIV/AIDS prevention should be displayed in communal areas. Free condoms should be provided in private areas such as toilets. Where construction workers live in a camp, a strict “No fraternization” policy should be maintained and workers restricted to leave or enter camp after 6 PM to discourage prostitution.

7.2.2.6 Gender-related Impacts

Impact identification

COVID-19 is expected to have different impacts on women and men, girls and boys. Women will be more affected in systems with more female health workers. As schools close and family members fall sick, the burden of care is likely to fall on women. Domestic violence may increase with stress and anxiety. Adolescent pregnancies may increase with school closures.

Impact evaluation

Sexual Exploitation, Abuse and Harassment: The risks of sexual exploitation, harassment, and abuse will be assessed, and mitigation measures put in place. Gender-Based Violence: Rates of GBV, especially Intimate Partner Violence have increased as people stay at home and change behavior in response to the spread of COVID-19.4 Other types of GBV are sexual assaults against children, disabled and the elderly. Mental Health: Epidemics can cause stress, anxiety and fear. Sources of stress at the household level may arise as children stay at home and create competing demands for time and income decrease due to job loss or wage cuts. The pandemic can also increase fear from lack of information.

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Routine Health Care and Essential Services: Resources are often diverted from routine health care services toward containing and responding to the outbreak. Women‟s Leadership and Representation: When women are underrepresented in decision making for outbreak prevention and response, their needs are less likely to be met. Data and Monitoring Systems: Sex- and age-disaggregated data is required to examine and respond to gendered patterns in mortality and vulnerability to COVID-19.

Impact severity

This impact is short-term but can have long-term and irreversible impacts such as injuries, psychological scars, family breakups, and etc.). The impact will potentially occur within affected families/communities. Likelihood of the impact occurring is high and significance is therefore predicted to be medium-high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high  Low- Medium Low Very- Low

Impact mitigation and management

Tables in Annexes 16 and 17 provide some for specific recommendations to address differentials between men and women during project preparation and implementation, and measures to address risks of GBV during COVID-19 Response.

7.2.2.7 Social impact of material transport

Impact identification

Various materials required for renovation works (sand, murram) will be transported to construction sites from various suppliers. This poses impacts associated with spills or dusting during transportation.

Impact evaluation

In the case of fine materials (crushed stone aggregate, sand, murram), dusting or spills on roadways can degrade local air quality or worsen driving conditions increasing risk of road accidents (e.g. shattering windscreens). This impact will manifest for health centers which are accessible by paved roads. This indirect, short-term but reversible impact will not be as significant on gravel roads as would be on these paved carriageways.

Impact severity

Impact duration is short-term only lasting the construction period, but secondary effects of road accidents will be long-term and possibly irreversible. Unless mitigation measures are instituted, likelihood of the impact occurring is high. Considering the relatively small quantities of materials needed during renovation of each facility (hence low traffic volume) impact severity is low, hence low-medium significance.

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Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high Low- Medium  Low Very- Low

Mitigation

Fine earth materials (sand, murram) should be covered during haulage to facilities under renovation to prevent spillage and dusting. Haulage trucks should have tailgates that close properly and tarpaulins to cover material being transported. The clean-up of spilled earth and construction material on the paved roads should be a responsibility of the Contractor and should be done in a timely manner (say within 2 hours) so as not to inconvenience or endanger road users. These requirements should be included as clauses in contractor‟s contracts. A grievance mechanism to address complaints from community shall be in place.

Impact management

The management of adverse impacts associated with materials haulage can be achieved not only through implementation above mitigation actions but also surveillance and supervision of construction contractors.

7.2.2.8 Temporary scenic blight

Impact identification

Construction activities will require material, equipment and cordons at healthcare facilities. Since facilities under renovation would not be closed from access by public, presence of these activities and materials thereof will cause temporary visual blight at all sites.

Impact evaluation

Presence of construction activities will alter visual impressions accustomed to at existing healthcare facilities.

Impact severity

Duration of visual impact will be short-term only lasting only the construction period. Likelihood of the impact occurring is high but considering the dilapidated state of all existing healthcare facilities under this project, this impact will have low significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high Low- Medium Low  Very- Low

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Mitigation

Wherever possible, contractors should ensure minimal footprint of construction activities.

Impact management

All unnecessary equipment should be removed from site as soon as possible.

7.2.2.9 Improper site drainage creating breeding grounds for disease vectors

Impact identification

Improper drainage of construction sites and ponding of storm water would create breeding grounds for disease vectors such as malaria-parasite transmitting mosquitoes.

Impact evaluation

Malaria mosquitoes would pose a negative public health impact to surrounding dwellings.

Impact severity

Duration of visual impact will be localized and short-term only lasting only the construction period. Likelihood of the impact occurring is high especially when construction is undertaken in wet seasons. This impact will have low- medium significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high Low- Medium  Low Very- Low Mitigation: Contractors should ensure proper site drainage.

7.2.3 Negative environmental impacts 7.2.3.1 Indoor air quality deterioration due to dust

Impact identification

Demolition to modify internal built environment will lead to considerable levels of indoor cement dust which can affect workers and patients.

Impact evaluation

Deteriorated indoor air quality would be of critical effect to especially asthmatic construction workers, patients and health workers with either minor or severe health impact depending on level and duration of exposure.

Impact severity

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Impact duration will be short-term occurring only during the construction phase. Extent of this impact will be local limited to interior of buildings being renovated. The likelihood of the impact occurring is high when control measures are not instituted but it is reversible. Significance of this impact is Low- Medium especially if it affected already ailing patients.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high Low- Medium  Low Very- Low

Impact mitigation

. Contractors should use dust screens or nets in windows, doorways and ventilators of rooms where demolition or other dusty construction activities are occurring. . Ensure good housekeeping and clean construction operations where, among other necessary actions, dust should be quickly swept off cement floors and collected in covered containers. . Patients shall not be allowed to construction areas.

Impact management

A senior healthcare administrator or superintendent at each facility should have authority to inspect and restrain contractors from generating excessive dust within healthcare buildings.

To minimize indoor dust, portable extraction systems are recommended but they might not be available among local contractors, or lack of electricity on site might limit their use. Water sprays are not practical and could lead to indoor flooding of surrounding rooms or service areas occupied by patients. A grievance mechanism to address complaints from community shall be in place.

7.2.3.2 Improper management of construction activities/ works

Impact identification

At each healthcare facility, renovation activities will involve demolition and construction activities that might generate considerable waste comprising brick and concrete rubble, metal, glass cullet and timber waste.

Impact evaluation

Improper disposal of construction waste could have environmental and public health impacts. This is of particular concern if demolition rubble contains friable asbestos.

Impact severity

Inappropriate disposal of construction waste can have medium or long-term environmental and public health impact. Extent of this impact will be local to areas where waste is dumped or their immediate neighborhoods. Likelihood of the impact occurring is high considering prevalent lack of facilities (monofills22 or even general waste landfills) to

22 Monofills are landfills designed for disposal of only one type of waste.

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handle construction waste in all areas comprising project facilities. Where inappropriately dumped construction waste contaminates environmental resources (soil and water) in communities or causes public health effects, significance of this impact would be high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation

. Contractors should undertake waste segregation at source to separate hazardous from non-hazardous waste. . Waste (such as metal scrap or wood waste) that can be reused/ recycled may be given to local people. . Waste hoarding at site before disposal should be at designated places and considering site lay-out in order not to block any exit routes and emergency routes. . Any hazardous materials shall be handled by NEMA licensed waste-handlers. Asbestos materials handling, management and disposal shall be undertaken following work-method instructions issued by NEMA. . Seek guidance of local environmental officers to identify acceptable disposal sites. . Contractors must provide suitable containment and storage of chemicals and hydrocarbons to prevent soil contamination and pollution to ground or water (surface and ground).

Impact management

Supervising engineers and local environmental officers should ensure that contractors do not illegally dump waste in non-designated areas. Local environmental officers (District, Town/ Municipal Environmental Officers) should be facilitated to undertake active monitoring roles during construction period. A grievance mechanism to address complaints from community shall be instituted.

7.3 Operation Phase Impacts 7.3.1 Positives social impacts 7.3.1.1 Improved medical services at healthcare facilities

The project will positively impact health of Ugandans through easing access to quality medical care currently non- existent at these facilities. Renovation of facilities and installation of medical equipment will enable currently ineffective healthcare facilities provide new or improved services to patients. Renovation of HCF will save money for poor people when it is no longer necessary to travel to distant medical facilities for healthcare services. This is a long- term secondary benefit.

Benefits of each project component are outlined in table below.

Table 9: Social benefits of each project component Project component Social impact 1 Component 1: Scaling up This component will improve: results based financing for frontline health services i) financial capacity of health centers

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Project component Social impact ii) functional efficiency in delivery of healthcare services iii) technical capability of health centers in service delivery 2 Component 2: Strengthening This component will bear the following social benefits: capacity to deliver scaled up i) Strengthened institutional capacity to deliver high impact and quality URMCHIP URMCHIP services services using pay-for-performance approach ii) The component will provide incentives to the Ministry of Health (MoH) at the center to implement priority health systems strengthening actions that will enhance national capacity to deliver of URMCHIP services and iii) Incentives to DHTs in selected districts to scale up delivery of URMCHIP services. iv) Improve and strengthen performance of healthcare service delivery through use of pay-for-performance schemes. 3 Component 3: Strengthen . Build institutional capacity for CRVS and scale up births and deaths registration capacity for civil registration services. and vital statistics (CRVS) . Support development and dissemination of a national CRVS policy and strategy . Finance procurement of the necessary materials, tools and equipment for BDR such as office equipment, IT equipment (computers and mobile phones) and BDR registers. . Establishment and operationalization of a CRVS monitoring and evaluation system, and promotion of the use of CR data for planning and accountability purposes. . Development of the necessary BDR protocols and manuals, including a community cause-of-death reporting tool using verbal autopsy; standard pre- service and in-service training curricula on certification of cause of death. . Scale up of birth and death registration at the sub-national levels. 4 Component 4: Capacity This component will support costs related to operations and overall management of Building, Results Verification the project. This component will support provision of technical assistance in the areas and Project Management of project management, external verification, financial management, procurement, monitoring and evaluation. Other activities under this component include: the collection of baseline data, coordination and implementation of the mid-term and end- of-project evaluation of all project components, and annual financial audits. The resultant benefit of the component will be beneficial socio-economic participation of local experts, their capacity strengthening and assurance of proper execution of the project thorough monitoring, evaluation and auditing. 5 Component 5: Ebola CERC Uganda will be better placed to effectively respond to EVD outbreak.

6 COVID-19 CERC Satisfactory containment of COVID-19 pandemic would avoid loss of live and grave socio-economic impact on Ugandan people. Currently the country has lowered its economic growth projection for this financial year by 0.3% to 0.8% from the targeted 6 percent for financial year 2019/2020. Schools and many other facets of public life have been shut down. Therefore COVID-19 in its worst scenario will impoverish millions of Ugandans.

Enhancement measures

The interventions under the project will involve improvement in provision of health services to culturally and socially diverse communities with different needs, attitudes and practices requiring adapted measures to ensure the full integration of all serviced communities, including the most vulnerable and marginalized groups (for example, the indigenous peoples).

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7.3.1.2 Employment opportunities

Equipping healthcare facilities with modern equipment, enabling provision of new healthcare services and resultant increase in visiting patients may create additional long-term technical and non-technical job opportunities for medical professionals, janitors and security guards.

7.3.1.3 Reduced public risks due to improvement in healthcare waste management

Proper management of medical waste involving segregation of hazardous from non-hazardous streams and safe disposal would mitigate existing public health risk associated with improper disposal of healthcare waste.

7.3.1.4 Improved aesthetics and life of healthcare facilities

Renovation of health centers will improve aesthetics of healthcare facilities some of which, in present state, look dilapidated. Renovation will also give healthcare buildings and equipment extended life.

Enhancement measure

Engineering design for proposed renovation works should incorporate a plan for routine maintenance and sustainability.

7.3.2 Negative social impacts

Key negative impacts during operation of renovated healthcare facilities will arise from: i) Community risk due to improper waste management (including medical waste, emissions to air and wastewater discharges), ii) Misuse or inability to use installed equipment for improved service delivery, iii) Lack of maintenance, hence facilities degenerating to decay again, iv) Occupational risk to health workers, v) Fire risk.

If they occurred, the above would mostly be cumulative impacts since they were observed at almost all facilities comprising the proposed project.

7.3.2.1 Community health risk due to improper waste management

Impact identification

Improper waste disposal can cause public health risks due to environmental pollution: impaired air quality, storm water contamination of water courses or when people and children rummage through raw waste stockpiles. Wastewater did not seem to pose considerable disposal challenge since all facilities either had onsite septic systems or sewage lagoons.

Impact evaluation

As already indicated, plume downwash leads to chronic exposure of nearby communities to potent air pollutants including dioxins. Infections (e.g. Hepatitis B) sustained when people or children rummage through improperly dumped infectious waste can be life-threatening.

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Impact severity

Unless mitigation recommendations are implemented, this impact will occur at all healthcare facilities. Likelihood of the impact occurring is high if incinerator stack designs are flawed or proper solid medical waste management practices are not instituted, and if common practices of burning all waste types in open air continue. Although it is a local cumulative impact, public health due to improper healthcare waste management has high impact significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation: Ensure proper waste management practices as recommended in the study on improvement of healthcare waste management in Uganda23.

Impact management

. Ensure regular monitoring of solid, liquid waste management practices and incineration. . Ensure proper management of pharmaceutical waste by engaging a consultant to develop measures and guidelines for each facility in accordance with the national healthcare waste management plan. . To ensure proper sewage management latrines shall be constructed where they do not exist. . Ministry of Health shall develop measures for proper management of expired pharmaceutical drugs and instigate this policy at all health care facilities.

7.3.2.2 Occupational health and safety risks

Impact identification

Beside loss of life, spread of COVID-19 in Uganda would have significant socio-economic impact on the country. The biggest impact would be on the services sector. Travel restrictions are already affecting the tourism sector including hotels, accommodation and transportation. Border closures and supply chain disruptions are hampering national and regional trade. Closure of learning institutions, public places and places worship is disrupting social, cultural and religious life of people.

COVID-19 is highly infectious and the risk of getting these diseases contracted by healthcare workers and the general public is high, if requisite training, sensitisation and protective gear are not provided.

Medical facilities are a potential source of infectious waste in gaseous, liquid or solid forms. These could pose unsafe conditions for healthcare staff. Of particular concern are janitors handling infectious waste (including sharps) without adequate protective gear, storage of sharps in containers that are not puncture-proof and management of radioactive waste at healthcare facilities where x-ray equipment will be installed. While some OHS risks will be new borne by equipment or services introduced after renovation or upgrade of facilities, most other effects are existing (hence cumulative) and would only be exacerbated by increased scale of healthcare services.

23 MoH 2005 (revised march 2009): Improvement of healthcare waste management in Uganda (conducted by Carl Bro)

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Below is a list of OHS risk sources for healthcare staff: i) Lack of adequate lighting in workplaces ii) Lack of safe access particularly for disabled employees iii) Inadequate ventilation in rooms iv) Lack of adequate training (or neglect of safety precautions/ guidelines) in use of medical equipment v) Misuse of equipment and materials for functions they are not designed vi) Lack of safety signage in specific areas (e.g. X-ray rooms) vii) Electrical hazard viii) Eye hazards such as splashes in laboratories and operating rooms ix) Chemical hazards (acids, alkalis, expired drugs, oxidizing and reactive chemicals) x) Radiological Hazards xi) Biological Hazards (blood or other body fluids with potential to cause diseases). Biological agents can be classified into four groups24:

1: Biological agents unlikely to cause human disease;

2: Biological agents that can cause human disease and are likely to require additional controls, but are unlikely to spread to the community;

3: Biological agents that can cause severe human disease, present a serious hazard to workers, and may present a risk of spreading to the community, for which there usually is effective prophylaxis or treatment available and are thereby likely to require extensive additional controls;

4: Biological agents that can cause severe human disease, are a serious hazard to workers, and present a high risk of spreading to the community, for which there is usually no effective prophylaxis or treatment available.

During routine facilities maintenance or repair, burns from welding / hot works or falls from working at heights might also occur.

Impact evaluation

A considerable number of healthcare workers get life threatening infections in the course of their normal duties. This is a negative and in some cases irreversible health impact.

Impact severity

Likelihood of the impact occurring is high unless control measures are instituted. Although it is a cumulative impact, the risk to human health has high significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium

24 World Health Organization (WHO) Classification of Infective Microorganisms by Risk Group (2004).

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Low Very- Low

Impact mitigation

The primary measure to mitigate OHS impacts is prevention which entails identification of risks and instituting proactive measures to avoid them. In part this can be achieved by following national guidelines. For unavoidable risks, personal protective equipment (PPE) should be provided to health workers.

Places of work involving occupational exposure to ionizing radiation should be provided with requisite protection established and operated in accordance with recognized international safety standards and guidelines. The acceptable effective dose limits appear in Table 10 below.

Table 10: Acceptable effective dose limits for workplace radiological hazards Exposure Workers (minimum 19 years of age) Five consecutive year average (effective dose) 20 mSv/year Single year exposure (effective dose) 50 mSv/year Equivalent dose to the lens of the eye 150 mSv/year Equivalent dose to the extremities (hands, feet) or skin 500 mSv/year

Impact management

Each healthcare facility should have a systemic risk management plan comprising risk prevention, evacuation of accident victims, evaluation and improvement measures.

7.3.2.3 Fire risk

Impact identification

Without provisions for fire safety, there is a risk of fire outbreak at healthcare facilities with disastrous life and financial impact. Fires can start from ignitable materials in laboratories, cigarette smoking in non-designated places or old electrical connections.

Impact evaluation: A large fire at healthcare facilities would have significant human and financial impact.

Impact severity

Likelihood of the impact occurring is medium-high since almost all healthcare facilities lacked fire extinguishers. The impact would be local in spatial extent affecting onsite facilities, patients, health workers and neighboring communities with possibly irreversible impacts. Impact significance is therefore high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

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Impact mitigation

. Provide fire extinguishers to healthcare facilities during their renovation. . Key healthcare staff should have basic training in fire control . Fire emergency telephone numbers should be displaced in communal areas

Impact management

. Each healthcare facility will prepare a fire emergency management plan. . Undertake fire drills at healthcare facility, at a minimum once a year.

7.3.2.4 Misuse or inability to use installed healthcare systems and equipment

Impact identification

This project would be in vain if healthcare staff had no requisite training and skill to use installed equipment for improved service delivery. This would be a significant, negative medium-term but reversible impact. Impact mitigation

Provide requisite training during equipment installation.

Impact management: Through regular supervision, ensure only trained authorized personnel operate equipment.

7.3.2.5 Lack of sustainability

When improved healthcare facilities are not continually maintained, they would quickly degenerate to pre-project condition. This would be a negative, significant medium-term impact of local spatial extent but reversible.

Impact mitigation: A Facility Maintenance Plan will be prepared and implemented at each medical facility Impact management: MoH should ensure there is always a budget to sustain healthcare facilities in the country in a functional state.

7.3.3 Negative environmental impacts 7.3.3.1 Air pollution from onsite medical waste incinerators

Impact identification

Incineration of hospital waste if carried out in inappropriate facilities could result into localized pollution of air with pollutants such as respirable ash, furans and dioxins. Dioxins are known to promote cancers in humans.

Impact evaluation: Downwash of incinerator emissions has potential to degrade indoor air quality of healthcare buildings or those of nearby offsite buildings.

Impact severity: Duration of onsite and offsite air pollution would be long-term lasting entire life on incineration units unless the deficient units are either decommissioned or improved. Likelihood of the impact occurring is high. Considering the gravity of potential air pollution on health of patients and nearby communities, this impact will have high significance.

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Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Mitigation

. Ensure operator of incineration unit is adequately trained to ensure efficient operation. . Consultations with potentially affected people should be done by design consultant to inform choice of location of incinerator at each site.

Impact management

. Engineering design of stacks on onsite brick incinerators should follow good international industry practice (GIIP) as outlined in World Bank‟s EHS Guidelines: Air emissions and ambient air quality, April 2007. . Inspection/ monitoring: Healthcare administrators should undertake regular visual inspection of incinerator stack for incidents of downwash and undertake annual monitoring of air quality or a general environmental audit of entire healthcare facility. . Training of incinerator operators is important for them to be familiar with basic principles and routine practices. For example homogenization of waste is crucial to ensure efficient and complete combustion during incineration to avoid generation of dioxins for instance when wet waste batches quench flames and lower combustion temperature below levels at which such pollutants are destroyed.

7.3.3.2 Improper medical waste management

Impact identification During their operation, health centers will generates medical waste in situations of absence of medical waste disposal facilities such as central incinerators or secure landfills. Prevalently waste will continue to be burnt in small onsite kilns without provision for air scrubbing. While this eliminates a solid waste challenge, it creates a risk of onsite and offsite air pollution that chronically affects patients and surrounding property owners.

Impact evaluation: Improper disposal of medical waste would have environmental and public health impacts.

Impact severity:

Inappropriate disposal of medical waste would have medium or long-term environmental and public health impact. Extent of this impact will be local to areas where waste is dumped or immediate neighborhoods. Likelihood of the impact occurring is high considering prevalent lack of facilities (appropriate waste incinerators, monofills25 or even general waste landfills) to handle medical waste. Where inappropriately dumped medical waste contaminates environmental resources (soil and water) in communities or causes public health effects, significance of which impact would be high.

25 Monofills are landfills designed for disposal of only one type of waste.

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Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Impact mitigation

It is widely known that simple kilns used by healthcare facilities in Uganda for combustion of medical waste lack air scrubbing provision and hence turn a solid waste problem into air pollution challenge. One solution is for Ministry of Health to devise strategies to stimulate private sector investment in centralised medical waste incineration or disposal facilities that would safely manage healthcare waste from collection to final disposal. The Ministry of Health is to consider HCWM at National level and develop practical way-forward and strategies to develop a network of appropriate facilities and procedures.

7.4 Social and Environmental Impacts of Ebola and COVID-19 Emergency Operations

While it is expected that COVID-19 and Ebola isolation centers will be developed at existing healthcare facilities, land / space might be required at very short notice in some cases which, due to social stigma, may not easily be availed by local land owners. Medical waste contaminated with COVID-19 or Ebola virus needs careful management to avoid socio-environmental impacts. This shows that, although fast and urgent, COVD-19 EVD emergency operations need careful planning from start to end.

Strategic operations in responding to COVID-19 and EVD emergencies entail the following activities:

. Surveillance, active case finding and follow-up of contacts, . Risk communication and community engagement . Enabling laboratory diagnostic capabilities in affected areas . Clinical care, isolation of suspected cases and follow-up of survivors . Infection prevention and control measures (IPC / WASH) . Psychosocial support (including for survivors of isolation induced GBV26) . Safe and dignified burials (SDB) . Operational preparedness of health centers near to epidemic foci . Coordination of the emergency response . Information management and monitoring and evaluation . Administrative management of human resources . Planning and financial management . Logistics management

Assessment of social-environmental impacts of COVID-19 and EVD emergency operations is presented in sections below.

26 Guidance on how to handle cases of GBV during the COVIC-19 Pandemic is included in Annex 18.

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7.4.1.1 Inadequate risk communication and community engagement

Impact identification

Emergency response interventions to outbreaks of COVID-19 and EVD often involve immediate top-down mobilization of medical teams and strict enforcement measures such as government prohibition of socio-cultural practices such as burial ceremonies weddings, religious gatherings, etc. Combined with poor local engagement, such responses in local communities often lead to widespread confusion, fear and misinformation.

Impact evaluation: Misinformation can endanger (foreign) medical teams when their activities are misunderstood or not known. In Congo for example, violent attacks on or murder of emergency teams have occurred arising from misconceptions that medical teams actually spread the killer disease among local citizens. Additionally, once local people are not educated about EVD/COVID-19 and EVD, its potency, how it is spread and control measures, they would not participate in its control. It would for example be difficult for families to isolate themselves or a relative or relegate their right to bury a deceased family member unless they are fully aware of inherent risk. a) Surveillance, active case finding, and follow-up of contacts would be resisted by households or communities harboring COVID-19 and EVD contacts if they have no strong understanding of COVID-19 and EVD and its fast debilitating effects. In fact, this is what might induce attacks on surveillance teams. Effective community sensitization will particularly be important for hard-to-reach communities and Indigenous Peoples that lack access to formal communication channels (print and electronic mass media).

Impact severity: While inadequate communication itself would be short-lived, its effects would be long-term in some cases involving death of family members, especially when they were family heads earning the household incomes. Likelihood of the impact occurring is moderate considering difficulty of access to remote communities, the vast length (550 miles) and porous nature of Uganda‟s border posts. In so far as inadequate communication and dissemination of COVID-19 and EVD risk will impede effective control of an outbreak hence lead to loss of lives and harm (violent attach) to emergency medical teams, this negative social-economic impact will have high significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high  High Medium - high Low- Medium Low Very- Low

Mitigation

Ministry of Health should:

. Involve local opinion leaders (LC 1 Chairpersons, Women Leaders, Youth Leaders, Members of Parliament, business associations and representatives of members of Vulnerable and Marginalized Groups (Batwas and Iks) in COVID-19 and EVD risks communication strategies. . Establish and train integrated Community Engagement Units (CAC) in risk-prone areas. . Intensify media campaigns mainly in rural areas, such as wireless radio and social networks using new information technologies (cellular phones); . Ensure regular updating of messages to render the response interventions less traumatic for the population, taking into account results from analysis of community feedback and socio-anthropological surveys. . Maintain a team responsible for harmonizing media actions (broadcasting rates, dissemination formats, journalistic ethics control, etc.);

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Impact management

. Training and sensitization of response teams for strict compliance with the Code of Conduct to promote protection from exploitation and sexual abuse, abuse and / or unethical behavior and to ensure follow up of complaints from the population . Ensure regular communication and community engagement training for stakeholders and communities on common myth, questions and appropriate responses, so they are able to answer questions about the multiple aspects of EVD and COVID-19. . Institute a Grievance Redress Mechanism to be used by any persons affected by CERC operations, paying special attention to vulnerable and marginalized people (e.g. Batwa and Ik) who may not access conventional redress mechanisms available to the wider community.

7.4.1.2 Impact of laboratory diagnostic capabilities in affected areas

Impact identification

It is essential that laboratory analysis is carried out to immediately ascertain or rule out a suspected COVID-19 cases & EVD outbreak. It is expected that COVID-19 and EVD samples collected during a suspected outbreak will be transported by Ministry of Health to a specialised reference laboratory for analysis in accordance with WHO and MoH standard operating procedures. This avoids the potential impact of improper laboratory waste disposal in communities or at emergency treatment units. Improper laboratory waste (syringes, GeneExpert cartridges etc) would lead to offsite COVID-19 and EVD transmission.

COVID-19 samples will be tested at Uganda Virus Research Institute (UVRI) which has all requisite facilities and protocols to control medical waste from COVID emergency operations.

Impact evaluation: Improper management of laboratory waste (syringes, GeneExpert cartridges etc) would lead to offsite COVID-19 and EVD transmission slowing effective containment of the outbreak.

Impact severity: Unplanned disposal of COVID-19 EVD-related laboratory waste would be a negative impact with potentially long-term and irreversible socio-economic impact with have high significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high  High Medium - high Low- Medium Low Very- Low

Mitigation

Ministry of Health should:

. Establish a quality control system for laboratory samples . Establish a (mobile) incinerator for destroying GeneExpert cartridges at higher than 1,200 °C . Put in place innovative and efficient mechanisms to improve transport of Transit Centre samples to reference laboratories in the shortest time possible.

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. Sample transportation should not expose transporters to risk either during normal handling or in case of an accident.

Impact management

Continue building the capacity of laboratory staff to meet necessary standards, including:

. Ensure waste management in accordance with existing WHO standard operating procedures (SOPs); . Adhere to SOPs on medical waste management detailed in Uganda‟s Standard Operating Procedures and Guidelines for Responding to COVID-19 & Ebola/Marburg Virus Disease Outbreaks in Uganda. A Guide for National Response, 2015 . Daily monitoring of laboratory capacity to ensure they are all able to accommodate the number of samples collected . Organizing sample management (collection, storage, packaging and transport); . Organizing training for COVID-19 and EVD diagnosis and sample management.

7.4.1.3 Improper clinical care, isolation of suspected cases and follow-up of survivors

Impact identification

The aim of clinical care for COVID-19 and EVD patients will be to provide high quality, safe care and individualized patient-centred care in a biosecure environment to minimize the risk of spreading these diseases to other patients or health workers. Clinical care includes medical, nursing, nutritional, rehabilitation, psychosocial care and early childhood care services - taking into account specific needs of indigenous people (Batwa & Ik), disabled persons, children and women, including pregnant and lactating women.

Impact evaluation: If this important undertaking is not planned or carried out with due caution, there is a big risk of transmitting COVID-19 and EVD infection to healthcare workers or other people in their families.

Impact severity: Onward infection of medical workers or other people due to improper clinical care, isolation of suspected cases and follow-up of survivors would be a negative impact with long-term and irreversible (if death occurred) socio-economic impact with have high significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high  High Medium - high Low- Medium Low Very- Low

Mitigation

MoH should:

. MoH should take special effort to ensure that services are amenable and accessible to Ik and Batwa who are vulnerable and marginalized people in Uganda. For example in case of an EVD outbreak, health personnel with specific knowledge of social their customs and culture should be included in teams providing emergency services to communities in which Batwa and Ik people live.

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. Improve biosecurity and harmonize care protocols to avoid risk of infections of medical workers and other people. . Build triage centres in referral hospitals or in health facilities according to the dynamics of EVD and COVID-19 pandemic. . Set up a management system specific to case management structures under the management of MOH (finance, logistics, administration, etc.) . Decentralize transit centres in the health facilities that are far from the ETCs; . Restructure the survivors‟ follow-up programme by fully integrating it into the clinical care.

7.4.1.4 Weak EVD infection prevention and control measures (IPC + WASH)

Impact identification

Infection prevention and control (IPC) measures and water, sanitation and hygiene (WASH) aim to prevent and control nosocomial (originating in a hospital) and community transmission of EVD and COVID-19.

Impact evaluation: Absence of effective IPC and WASH measures would curtail efforts to control EVD and COVID- 19. This reiterates the importance of precautions such as avoiding handshaking, hand washing with chlorine solutions and use of alcohol-based sanitizers. In addition burial of EVD and COVID-19 victims should be left to to specialized healthcare teams.

Impact severity: Absence or weak EVD and COVID-19 infection prevention and control measures would lead to uncontrolled spread of EVD and COVID-19, a negative long-term and irreversible (if death occurred) socio-economic impact with have high significance.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high  High Medium - high Low- Medium Low Very- Low

Mitigation a) Main activities in the health facilities:

. Strengthen training activities of healthcare providers and IPC supervisors . Implement the IPC package that includes standard operating procedures (SOPs),tools, rapid diagnostic tests . Strengthen the IPC / WASH support system in health facilities based on health facility assessments, training supervision with corrective actions, and the establishment of a quality assurance system in close collaboration with the independent monitoring and evaluation team . Evaluate and implement WASH infrastructures and services in health facilities. . Provide health facilities with IPC / WASH inputs (chlorine) as needed and monitor their use. . Ensure the decontamination of health facilities that have received confirmed EVD and COVID-19 cases. . Ensure implementation of the IPC ring approach around each confirmed case of EVD and COVID-19.

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b) IPC in affected communities

In communities, IPC activities should be carried out in households and in public places. These include:

. Ensuring access to water and sanitation in schools and public places . Ensuring decontamination of households and public places that have had confirmed COVID-19 and EVD cases . Providing hygiene kits to households, schools and public places . Strengthening the monitoring and evaluation system . Training community leaders in COVID-19 and EVD prevention . MoH should take special effort to ensure that VHT or other healthcare providers effectively include Indigenous Peoples communities. For example in case of COVID-19 & EVD outbreak, health personnel with specific knowledge of their social customs and culture should be included in teams providing emergency services to Indigenous peoples.

WHO‟s guidance on key questions and answers concerning water, sanitation and hygiene (WASH) is presented in Annex 15.

7.4.1.5 Weak psychosocial support

Impact identification: Through psychosocial care, MoH aims to promote community cohesion and strengthen resilience of families to reduce stigma.

Impact evaluation: If designed well, psychosocial support systems would achieve expected aims but if weak, the systems would leave stigmatized families and communities during and after COVID-19 and EVD emergency response.

Impact severity: Absence or weak psychosocial support systems would impede effective prevention of stigma attached to EVD and COVID-19, a negative but short-term and reversible impact, reducing or ceasing with heightened awareness. Therefore impact significance will be medium-high.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High Medium - high  Low- Medium Low Very- Low

Mitigation

. Strengthen psychological support for ETCs (for confirmed, suspected, and discharged cases) and assistance with hygiene kits for all discharged and cured patients; . Strengthen psychosocial activities in schools and support teachers who support prevention and monitoring of COVID-19 and EVD and also participate in reintegration of orphans and offer them psychosocial support. . Support nurses at ETCs to provide psychological support to people in isolation, especially children; . Ensure capacity building of psychosocial workers and clinical psychologists; . Ensure material assistance (beddings, utensils, clothing, as necessary) following assessment of affected families and orphaned / separated children;

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. Ensure nutritional monitoring in communities; . Provide nutritional assistance to survivors, orphans and infants separated from their families; . Provide psychological follow-up for survivors of the diseases and of mitigation of issues such as induced GBV; . Provide psychological support to confirmed cases, suspects and accompanying persons / families; . Provide psychosocial support through visits to affected families and orphaned / separated children; . Support affected households to anticipate management of behavioral problems, which can generate tensions and resistance in the community.

7.4.1.6 Safe and dignified burials (SDB)

Impact identification

For many tribes and religions in Uganda, a common traditional practice is to wash bodies before burial. However, the risk of contracting COVID-19 & EVD is high if handling of dead bodies is not minimized. Therefore, the objective of safe and dignified burials (SDB) is to prevent transmission of COVID-19 or EVD through safe and dignified burial of confirmed, probable or suspected cases. People whose lives have been claimed by COVID-19 & EVD are not buried by their families but by specialized healthcare teams wearing necessary PPE and taking appropriate precautions based on World Health Organization (WHO) guidelines27.

Source: https://ebolaresponse.un.org/ebola-cases-decline-liberia-safe-burials-critical-achieving-zero-infections Plate 7.1: Safe and dignified burial

Impact evaluation: There are very strong social and emotional sentiments associated with families being unable to bury their deceased family members or friends, when this role is taken over by healthcare teams. In some cases violent disagreements have erupted between local communities and health teams about who should bury the deceased persons. Inadequate sensitization about the practice and its importance has in some community caused consternation about SDB. In some cases communities have complained about burial teams not respecting the dead during burials. Strange but not uncommon misconceptions in some communities are that burial teams dismember bodies, harvest organs, or take blood from the dead body, and that is the reason that family members are not allowed to observe burials. Once these myths are not cleared through comprehensive sensitization of local communities, misconceptions, fear, anguish and in some cases violent attacks on SDB teams have been reported28.

27 WHO Safe Burial Protocol (https://www.who.int/csr/resources/publications/ebola/safe-burial-protocol/en/) Accessed 21Nov2019 28 Source: https://www.tandfonline.com/doi/full/10.1080/10810730.2016.1209601 (Acc: 21Nov2019)

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Impact severity: While social stigma associated with burials is strong in many Ugandan communities, it is even greater if families do not pay last respects to their deceased members. This leaves a long-term negative social impact of high significance, on affected families. However, when communities are given prior sensitization about SDB and its importance to public health this social stigma would be lessened.

Impact significance

Significance color Significance Rating Significance level of code this impact Very high High  Medium - high Low- Medium Low Very- Low

Mitigation

. Ensure local communities are satisfactorily sensitized and aware of SDB and its importance; . Adhere to WHO Safe Burial Protocol; . Train and pre-position an SDB Team in local communities, preferably adopting a member of the local community on this team; . Ensure SDB teams are fully knowledgeable about WHO SDB protocols and associated activities including decontamination, community involvement and psychosocial support;

7.4.1.7 Inadequate logistics or their inefficient management

Impact identification

Inefficient logistics would slow COVID-19 and EVD emergency response efforts, possibly leading to higher mortality than would otherwise occur. The same impact would arise if required resources were inadequate to suitably contain an outbreak commonly, inefficiencies can arise from:

. The mismatch between the volume of leased vehicles at very high overall cost and the volume of work; . Insufficient number of ambulances, and motorcycles, particularly in the new response areas; . Lack of information regarding medical stocks or supplies; . Untimely breaks in the stocks of medical supplies; . Absence of standard operating procedures (SOPs) for logistics that govern all response stakeholders, and weak capacity of logisticians;

Impact evaluation: managing Emergency response might also entails supply of associated necessities such as food, clothing, beddings and utensils to COVID-19 & EVD survivors all of which require efficient management of logistics.

Impact severity: Inadequate logistics (or inefficient management thereof) would slow response operations, potentially leading to higher than expected COVID-19 mortalities. This would be a negative, irreversible socio- economic impact with a very high impact significance and social cost at local and national levels.

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Impact significance

Significance color Significance Rating Significance level of code this impact Very high  High Medium - high Low- Medium Low Very- Low

Mitigation

. Standardization of inventory management tools and mechanisms; . Checking needs for medicines, specific inputs and consumables; . Empowering partners to take over the supply of inputs for the activities for which they are responsible; . Independent responsibility of each partner for its activities (logistical support: accommodation, means of communication and IT, transport, etc.); . Strengthening the package of shared logistics services for efficient response;

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8 ENVIRONMENTAL AND SOCIAL SCREENING PROCESS

8.1 The Environmental and Social Screening Process

The sections below illustrate the stages (steps 1-7) of the environmental and social screening process leading to the review and approval of the project activities. The purpose of this screening process is to determine which activities are likely to have negative environmental and social impacts; to determine the level of required environmental assessment; to determine appropriate mitigation measures for activities with adverse impacts; to incorporate mitigation measures into the sub- program as appropriate; to review and approve the sub-program‟s proposals; to monitor and report environmental parameters during the implementation of activities. The extent of environmental work that might be required prior to the commencement of the sub-programs will depend on the outcome of the screening process described below.

8.2 The Screening Steps The environmental and social process of screening consists of the following steps:

Step 1: Screening of the Sub-Programs

The objectives of environmental screening are: to evaluate the environmental risks associated with a proposed operation; to determine the depth and breadth of Environmental Assessment (EA); and to recommend an appropriate choice of EA instrument(s) suitable for a given project. Criteria for classification include type, location, sensitivity, and scale of the project, as well as the nature and magnitude of its potential environmental impacts. Project screening will be based on a project brief prepared by the Environmental Health Division (EHD) of the MoH. However while this requirement is in line with the EIA process of Uganda, Project Briefs (PBs) may not be required for simple civil works and construction, since ESMPs prepared following screening as guided in the ESMF would suffice to handle impacts that may arise.

Screening will be carried out by the Town/ Municipal or District Environment Officer at local government level. Every district, Town or Municipal Council in Uganda has a Municipal or District Environment Officer (MEO/DEO) employed by the District Local Government. These environmental officers are trained and experienced in environmental management and EIA procedures. The District Environment Officer will complete the Environmental and Social Screening Form (see Annex 1) to facilitate identification of potential environmental and social impacts, determination of their significance, assignment of appropriate environmental category (see Box 1 below), appropriate environmental mitigation measures, and where required recommend undertaking of an Environmental Impact Assessment (EIA). According to World Bank, projects are assigned categories A, B, or C in descending order of environmental and social sensitivity as shown in Box 1 below.

Box 1: Definition of environmental categories of projects according to World Bank/ IFC

Category A: Projects expected to have significant adverse social and environmental impacts that are diverse, irreversible and unprecedented. Indicative List of Category A Projects:  Large-scale infrastructure: ports and harbor development, transport (rail, road and waterways), large- scale water resources management (river basin development, water transfer); dams and large reservoirs, hydropower and thermal power, extractive industries and oil and gas transport;  Large-scale agriculture, irrigation, drainage and flood control, aquaculture; agro industries, and production forestry;  Major urban projects involving housing development, water treatment, wastewater treatment plants, solid waste collection and disposal;  Industrial pollution abatement, hazardous waste management, industrial estates, manufacture and large-scale

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use of pesticides; and Projects that, regardless of scale or type, would have severe adverse impacts on critical or otherwise valuable natural or cultural resources. Category B: Projects are expected to have limited adverse social and or environmental impacts, site specific and can be readily addressed through mitigation measures Indicative List of Category B Projects:

 Small-scale infrastructure projects: power transmission and distribution networks, rural electrification, mini (run of the river with no major water impoundments) or micro-hydropower projects, small-scale clean fuel fired thermal power plants, renewable energy (other than hydropower), energy efficiency and energy conservation, rural water supply and sanitation, road rehabilitation, maintenance and upgrading; telecommunications, etc.;  Health care service delivery, HIV-AIDS, education (with limited expansion of existing schools/buildings), repair/rehabilitation of buildings when hazardous materials might be encountered (e.g., asbestos, stored pesticides); and

Small-scale irrigation, drainage, agricultural and rural development projects, rural water supply and sanitation, watershed management and rehabilitation, and small-scale agro-industries, tourism (small-scale developments). Category C: Projects are expected to have minimal or no adverse impacts Indicative List of Category C Projects:

 Education and Health projects not involving construction;  Construction or rehabilitation of a limited number of small buildings (e.g., schools or health clinics where health care waste is not an issue); and  Institutional development, training and certain capacity building activities. Source: www.worldbank.org

Step 2: Assigning of Environmental Categories

Assignment of appropriate environmental category to a particular activity will be based on information provided in the environmental and social screening form that the Municipal/ District Environment Officer will have administered. There is no project activity envisioned to require a full EIA (Category A) given the fact that the construction is a small scale expansion program, site-based and using mostly local procured materials, and besides the overall project EA category is B.

Step 3: Carrying out Environmental Assessment

After analyzing data contained in the environmental and social screening form and having identified the right environmental category and hence scope of the environmental assessment required, the MEO/ DEO will make a recommendation to Environmental Health Division (EHD) of the MoH as to whether: (a) no EIA will be required; (b) implementation of simple mitigation measures will be required and thus development of ESMP/Project Brief; or (c) a separate environmental impact assessment EIA will be carried out (such activities are not anticipated).

In case of activities under (a) and (b) above, project environmental and social mitigation measures checklist will be used (see Annex 2): Using the checklist the environmental and social mitigation measures will be proposed by the Municipal/ District Environment Officer at high Local Government level and an ESMP developed (as shown in Chapter 10). Alternatively, following the Uganda EIA guidelines, a Project Brief containing the ESMP shall be developed and submitted to NEMA for review and approval. In case of project activities falling under (c) above, an Environmental and Social Impact Assessment (ESIA) will be carried out by an ESIA practitioner approved by NEMA. The ESIA will be undertaken in accordance with the NEMA-approved terms of reference.

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The ESIA will identify and assess the potential environmental impacts for the planned activities, assess alternative solutions and will design the mitigation, management and monitoring measures to be adopted. These measures will be quoted in the Environmental and Social Management Plan (ESMP) that will be prepared as part of the ESIA for each sub-program. The preparation of the ESIA and the ESMP will be done in consultation with all relevant stakeholders, public institutions, including the people likely to be affected by the sub- program, and will be provided to the WB for a “no-objection” before commencing project implementation.

The ESIA will follow the national procedure established in the framework of the Environment Management Act, EIA Regulations, Guidelines and consistent with the WB OP 4.01. In situations where the screening process identifies the need for land acquisition, qualified service providers will prepare a RAP (Resettlement Action Plan), or Abbreviated RAP consistent with the OP 4.12, and the Resettlement Policy Framework (RPF) that has been prepared as a separate document for this program.

Step 4: Review and Approval

Review: At the district or municipal level, the Municipal/ District Environment Officer, and communities will review the environmental and social screening forms and will make recommendations as to whether the results of the screening process are acceptable. If a Project Brief was prepared to facilitate screening, it will be submitted to NEMA for review and/or approval. In case an ESIA needs to be undertaken, the ToR‟s for the study will be prepared by Environmental Health Division (EHD) of the MoH, reviewed and approved by NEMA, with modifications where necessary.

Approval/Rejection: The ESIA study will be undertaken by the EIA practitioner in accordance with the ToRs approved by NEMA and report submitted to NEMA for review. A Project Brief on the other hand may be prepared by either the client or hired consultant/s and the report submitted to NEMA for review/approval. NEMA will then forward copies to relevant Lead Agencies and Local Authority (MEO/DEO) for comments. Comments from the Lead Agency/ Local Authority will be considered by NEMA in making a final decision on project implementation. If the ESIA is approved, NEMA issues an environmental permit that confirms the EIA has been satisfactorily completed and the proposed sub-program implementation may proceed.

The ESIA will be submitted to WB for non-objection prior to the approval by NEMA.

Step 5: Public Consultations and Disclosure

Public consultations will take place during the environmental and social screening process, and the input from the public consultations will be reflected in the design of the mitigation and monitoring measures. The District/Municipal Environment Officer will communicate the results of environment and social screening to the Town Clerk/ Chief Administrative Officer (CAO) who will in thereafter, communicate the result to the MOH and Local Governments.

According to the procedures governing the EIA, public information and participation must be ensured during the scoping period and the preparation of the terms of reference of the Environmental and Social Impact Assessment. This will be done by EIA practitioner. The involvement of District/Municipal Environment Officer, District/Municipal Community Development Officer, Health Officers level will be encouraged. Public consultations include particularly:

. One or several meetings for presentation of the sub-program with a gathering of local authorities, the populations, the concerned organizations; . The opening of a register available to all the populations where will be consigned the preoccupations, the appreciations, remarks and suggestions formulated on the program.

World Bank requires disclosure of the environmental assessment report and/or ESMP both in-country by the client (MoH) and at WB‟s Infoshop by IDA.

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Step 6: Environmental Monitoring

Environmental monitoring aims at checking the effectiveness and relevance of the implementation of the proposed mitigation measures. Local councillors, District Environment Officers and local government Health Officers as well as concerned citizens will undertake monitoring exercises as provided for by the National Environment Act. The Municipal/ District Environment Officer in conjunction with the District Health Officer /Inspector will monitor implementation of environment mitigation measures based on the contractor‟s work plan. MOH in collaboration with NEMA will monitor implementation of the environmental mitigation measures on a sample of project sites on quarterly basis. On annual basis the Municipal/ District Environment Officers, MOH in collaboration with NEMA will carry out a national assessment of project performance in environment and natural resource management using the indicators mentioned in step 7.

Step 7: Monitoring indicators

The monitoring indicators that will be under ESMP for assessing environmental management for the project include:

. Construction management requirements . Medical waste management . Compliance with Legislations.

Use of the indicators for environmental monitoring will be included in the training and capacity building program.

A screening form for COVID-19 emergency operations is provided in Annex 1.

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9 PROJECT IMPLEMENTATION ARRANGEMENTS

9.1 Institutional and Implementation Arrangements

The project will be implemented by the MoH and the NIRA. The MoH is the main recipient, and NIRA, a sub-recipient under the MoH. Each agency will execute specified activities in line with their respective mandates. MoH will be responsible for activities under Components 1, 2, 4, 5 and 6, while NIRA will be responsible for activities under Component 3.

The Permanent Secretary (PS) of MoH, as the “Accounting Officer” of the Project, is responsible for overseeing implementation. The PS will delegate the day-to-day management of the project to a full-time project coordinator (PC). Senior officers at the rank of commissioner or head of department (and above) will be assigned as component coordinators to coordinate implementation of project activities under each respective components. A Project Steering Committee chaired by the PS (MoH), and composed of the Director General (MoH), Executive Director (NIRA), and senior officials from the two agencies will oversee Project implementation.

Project implementation will be mainstreamed within the operations of the MoH and NIRA. This is to ensure that Project implementation is aligned with national processes and systems, thus enhancing coordination and sustainability of programs. Where necessary, consultants financed by the Project, will be recruited to support implementation of Project activities components.

Coordination of implementation for Components 1 and 2 will be done through the existing technical working groups and respective departments/divisions of the MoH. It will be the responsibility of the PC to provide quarterly reports to Senior Management and the Top Management Committees of the MoH. For Component 3 under NIRA, coordination will also be through the existing technical working groups in NIRA under the supervision of the Senior Management Committee. The PC will also provide quarterly reports to the NIRA senior management to ensure coordination and harmonization of policy proposals and decisions affecting BDR.

A dedicated RBF Implementation Unit established at the MoH to coordinate RBF implementation will be responsible for coordinating project RBF activities. This unit will provide technical support and coordinate the rollout of RBF activities under the project. The RBF unit will further be supported by regional teams that will be responsible for supervision and coordination of district teams. The Health Sector Budget Working Group will perform the function of the national RBF steering committee.

The District Health Officer (DHO) will oversee implementation of project activities at the district level. The DHO assisted by an EDHMT will provide oversight functions including coordination of RBF activities at district level. At the health facility level, the HUMC will oversee all project-related activities executed by the facility. The operations of the RBF at the district level will be based on the Memorandum of Understanding signed between the MoH and districts on one hand and the district and health facilities on the other hand.

Implementation of EVD response operations will entail key pillars below:

. Coordination and leadership: to facilitate activation of Sub county coordination Task Forces especially in high priority areas within Category 1 districts to enable community led interventions.

. Surveillance: Train village health teams (VHTs) and health workers attached to priority points of entry (PoEs) on EVD screening, management including referral of suspected cases.

. Risk communication: Facilitate sensitization meetings with district, subcounty and community leaders including religious leaders, political leaders, law enforcement, cultural leaders, traditional healers, education

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staff, Voluntary Health Teams, and private health practitioners on COVID-19 and EVD management to ensure broader participation and capturing of contextual issues on EVD management

. Logistics management: Facilitate electronic Logistics Management Information System (eLMIS) in all district stores to manage distribution and monitoring of COVID-19 and EVD response supplies. . Case management and treatment: Provide adequate staffing and risk and others allowances for deployed staff in isolation units, ETUs and ambulances. Procurement, production and dissemination of treatment guidelines, job aids, booklets and/or posters. Facilitate setting up and decommissioning of waste disposal systems (direct flame incinerator with a capacity of 1400-1600oC to be installed in Naguru Regional Referral Hospital (RRH), Arua RRH, Kasese and Hoima RRH.

. Vaccination and treatment: Facilitate mobilization, supervision and monitoring EVD vaccination in high risk districts and treatment/monitoring for COVID-19.

9.2 Sustainability

The project will consolidate and scale up implementation of selected URMCHIP interventions using existing institutional mechanisms. The majority of these interventions are not new and are already under implementation. The project will help to address the critical health systems bottlenecks for the delivery of URMCHIP services, giving special attention to strengthening management of the health workforce; provision of critical inputs, such as, equipment and essential medicines; strengthening supply chain management; and strengthening systems for management of health information and support supervision. By addressing these systems bottlenecks, the project will ensure functionality of the existing systems and improve effectiveness of the frontline service providers in the delivery of URMCHIP services. The emphasis on addressing system-wide constraints will ensure that the delivery of URMCHIP services will become more sustainable.

The financial impact of the project on Government‟s health spending will be felt mainly in terms of additional resources to sustain implementation scale up. The project is part of the broader Government program under the SWAp and it is included within the Government‟s Medium-Term Expenditure Framework (MTEF). As outlined in the URMCHIP Sharpened Plan for Uganda, the total committed/pledged resources for URMCHIP activities is US$1028 million representing US$231 million from the Ugandan Government and US$797 million from development partners over the period 2016-2020.

CERC for COVID-19 and EVD, will run for 12 months after which, Uganda Government, together with other development partners will take over full responsibility for financing these emergencies.

9.3 Monitoring socio-environmental aspects comprised in this ESMF

At National Level, MoH will hire an Environmental Specialist as part of the project support team who will take lead in guiding and implementing environmental requirements of the project, working in close collaboration with the respective District Local Governments. Town/Municipal or District Environment Officers will be the key personnel responsible for monitoring the environmental and social impacts of the project. There is also a possibility of hiring supervising consultants to monitor the construction phase and these will be required to have Environmental and Social Specialists on their teams to monitor environmental and social aspects respectively. As earlier indicated, Town/Municipal or District Environmental Officers have requisite training and expertise to undertake necessary monitoring. However, their technical capacity will be enhanced by induction training at the beginning of project implementation. This will facilitate a better understanding and appreciation of safeguard requirements through discussion of modalities for implementation of the project ESMF provisions. Financial facilitation would however be necessary for their effective participation.

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9.4 Results Monitoring and Evaluation

The project‟s results monitoring and evaluation framework is consistent with the monitoring and evaluation (M&E) frameworks of the MoH and NIRA. The Results Framework allows for the monitoring of project implementation and assessment of achievement of its development objectives and focuses on accountability for results. The data will be collected from three main sources: HMIS under the MoH, civil registration database under NIRA, and the project‟s specific database. In addition, project implementation agencies will collect key information specific to the project for measuring and verifying agreed results for the DLIs and the RBF. The Resource Center in the MoH and the M&E Unit under NIRA will be responsible for coordinating M&E activities under the project. An M&E specialist will be recruited to support the process in the MoH.

Every quarter, the MoH will provide quarterly progress reports and quarterly Interim Financial Reports for onward submission to the Bank in accordance with the reporting requirements set out in the Operations Manual. For reimbursement purposes, the DHMTs will on a quarterly basis submit verified reports to the MoH for payment after certification by the RBF unit. The independent verification agent will prepare semiannual verification reports. Furthermore, a mid-term review will provide the opportunity to assess progress and make appropriate mid-course corrections.

9.5 Capacity enhancement needs

Assessments undertaken during compilation of the ESMF indicate a need to strengthen capacity of Environmental Health Division in MOH and NIRA for timely and quality execution of project activities. Training required entails:

. EIA process in Uganda . Environmental aspect-impact relationship . Impact assessment . World Bank Safeguards . Environmental monitoring . Stakeholder engagement . Grievance management . Management of environmental and social aspects of civil works management in Health Care Facilities . Health Care Waste Management

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10 KEY FINDINGS FROM STAKEHOLDER CONSULTATION

10.1 Findings from Ik indigenous people

The Ik people of Kaabong district are indigenous minority people. They did not report need for healthcare services specific to their culture and traditions. There was also no mention of unique diseases limited to their community. A key concern reported by Ik people was that Kamion Health Centre II which they visit had no Ik language-speaking staff work in it. This causes uneasiness for Ik patients visiting a health facility where their language is neither spoken nor their culture known. For instance after birth, Ik mothers take and preserve their placentas but this may not easily be allowed in a healthcare facility, the reason they resort to using traditional birth attendants.

10.2 Findings from Batwa indigenous people A meeting held in Kanungu District with Batwa indigenous people led to the following findings29: i) Diseases Batwa community noted as prevalent were: Malaria, diarrhoea, cough, ulcers, allergy and HIV. iii) Language used for communication at health centers: Language of communication at the nearest HC is Rukiga and Batwa people, who speak it fluently, said were comfortable with it. iv) Traditional or cultural practices: Batwa parents cut marks on children‟s chests and these are believed to prevent or treat pneumonia. It was also found that Batwa people believe false teeth are important and do not seek medical attention to remove them from infants. It was also revealed that generally Batwa people believe that traditional healers cure or prevent witchcraft, false teeth and pneumonia, therefore they consult them first and only visit a health center when the healers fail to provide solutions. v) Healthcare challenges mentioned:

. Patients referred by VHTs and HCs for further management do not have transport to their destinations. They are usually carried on locally made stretchers for long distances; . Lack of IPD, especially maternity ward for mothers to deliver from; . Lack of dental services and as a result, people use crude implements such pliers to extract bad teeth (this without anesthesia!);

A focus group discussion with Batwa women revealed the following:

. Lack of maternal ward, hence expecting mothers travel long distances to Bwindi Hospital to deliver. Some do not make it. . Women cited a general lack of access to sanitary facilities; . Mothers and children lack transport to HCs; . Batwa women who are financially disadvantaged wait in queues at HCs for long periods, which leads to loss of lives.

10.3 General views from other stakeholders consulted Most places reported malaria and diarrhea as common illnesses, and rare but dangerous diseases included Hepatitis B, Sleeping sickness and TB. In addition, most communities in Uganda have cultural beliefs and practices attached to pregnancy and child birth which may prevent mothers from seeking medical services.

29 Similar measures will be taken if Iks are to benefit from project’s activities related to COVID-19 management.

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10.4 Health Centres Health centers were reported to perpetually lack medical supplies and healthcare staff, and offer services beyond their intended level. For example Kamion HC II was reportedly supposed to have nine staff but has only three healthcare workers and offers other services meant for HC IIIs for example, antenatal care (ANC), family planning, deliveries and in-patient (Admission) all with only one bed. HCs were also reported to lack cemeteries for disposal of unclaimed bodies. Many lacked waste disposal (incinerator) facilities; and staff housing facilities. Common diseases handled included malaria, Respiratory Tract Infections (RTIs), Diarrhoea, Gastro-interties, eye infections and skin diseases. It was noted that land belong to medical facilities was increasingly getting encroached for settlement and cultivation with little help from local government authorities. The main reasons acerbating this was lack of enforcement of physical planning regulations and healthcare facilities land often lacking title deeds.

10.5 Village Health Teams (VHTs) Village Health Teams (VHTs) were reported to exist and functioning in all sub-counties and villages. The VHTs reported a number of challenges including difficulty of communication including impassable roads, lack of means of transport to reach far areas and poor cellular networks in rural areas.

10.6 Recommendations made by stakeholders Specific recommendations by Ik indigenous people:

. Consider language and cultural needs of Ik people in staffing health centres to break communication and cultural barriers when they visit health centres (Ik community), . Construct more health centres to accommodate the ever rising patients numbers, . VHTs should be supported in areas of transport, . HCs should be provided with adequate facilities and healthcare staff, . HCs should have adequate facilities for medical waste management and disposal of unclaimed bodies, . HCs should legally acquire ownership of land and fence it off to avoid encroachment.

Specific recommendations by Batwa indigenous people:

. Upgrade a HC II in their community to offer IPD services, including maternal care; . Recruit professional midwives to help women to deliver; . Provide motorcycle ambulances to take pregnant women to the HCs . Provision of ambulances (vehicles or motorcycles); . Upgrade and facility one of the nearby HC IIs to a level to offer in-patient department services, especially maternal services; . Provide dental service equipment and personnel; and . Provide and install Solar equipment

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11 ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN (ESMP)

An Environmental and Social Management Plan (ESMP) for the proposed project is intended to ensure implementation of environmental and social management of its activities. An ESMP translates recommended mitigation and monitoring measures into specific actions that will be carried out by the proponent.

The ESMP relevant to the project should be prepared as part of ESIA for project facilities and implemented throughout project life-time. The main components of an ESMP are described in table below (and example provide in Annex 6), which reflects practice at the World Bank. Ideally the ESMP should contain the following: i) Summary of the potential impacts of the proposal; ii) Description of the recommended mitigation measures; iii) Description of monitoring activities and plan; iv) Allocation of resources and institutional responsibilities for plan implementation and training; v) Implementation Schedule of the actions to be taken and reporting procedures; vi) Program for surveillance, monitoring and auditing; and vii) Contingency plan when impacts are greater than expected. viii) Estimated related costs and sources of funds

Table 11: Components of ESMP ESMP Component Components of ESMP Summary of The predicted adverse environmental and social impacts for which mitigation is required impacts should be identified and briefly summarized. Cross referencing to the ESIA report or other documentation is recommended. Description of Each mitigation measure should be briefly described with reference to the impact to which it mitigation relates and the conditions under which it is required (for example, continuously or in the measures event of contingencies). These should be accompanied by, or referenced to, project design and operating procedures which elaborate on the technical aspects of implementing the various measures. Description of The monitoring program should clearly indicate the linkages between impacts identified in the monitoring EIA report, measurement indicators, detection limits (where appropriate), and definition of programme thresholds that will signal the need for corrective actions. Institutional Responsibilities for mitigation and monitoring should be clearly defined, including arrangements arrangements for co-ordination between the various actors responsible for mitigation. Implementation The timing, frequency and duration of mitigation measure should be specified in an schedule and implementation schedule, showing links with overall project implementation. Procedures to reporting provide information on the progress and results of mitigation and monitoring measures procedures should also be clearly specified. Cost estimates These should be specified for both the initial investment and recurring expenses and sources of for implementing all measures contained in the ESMP, integrated into the total project costs, funds and factored into loan negotiations. Source: World Bank, 1999

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12 EBOLA AND COVID-19 SURVEILLANCE CHANNELS IN UGANDA

MoH has developed a two-pronged approach for EVD and COVID-19 surveillance as shown below. Both approaches help communities and healthcare workers to know who to contact in-case of suspected EVD or COVID-19 case in a given area: i) Indicator-based surveillance:

In this approach the reporting channels are from local healthcare facilities to District Health Office and finally to Ministry of Health headquarters in Kampala City.

Local HCF District Health MoH Headquarters

Office (DHO)

ii) Event-based surveillance

In this approach, information from village health teams (VHT) is transmitted to the District Health Office and onward to Ministry of Health Headquarters‟ Public Health Emergency Operations Center (PHEOC) and Call Center.

VHT DHO MoH Headquarters

PHEOC Call Center

iii) Toll-free numbers

Uganda‟s ministry of health has issued to the public toll free numbers and SMS lines30 to report suspected COVID-19 cases for its immediate action.

30 For information on COVID-19, call Ministry of Health toll free: 0800 100066, 0800 203033 or send a free SMS to Ureport on 8500

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12 PROTOCOL TO MANAGE CHANCE FINDS

This protocol will apply where healthcare facilities are to be constructed, especially when earthworks are carried out. Earthworks may encounter cultural and archaeological resources or chance finds. Construction can also reveal these buried resources, necessitating "salvage archaeology" for their recovery and protection. Once first stages of earthworks show signs of likely presence of archaeological resources, salvage entails quick excavation to remove artefacts or other traces of human settlement before extensive earth-moving continues. As a general construction principle, any archaeological “chance finds” should be handed to the Department of Museums and Monuments in the Ministry of Tourism, Trade & Industry (MITI).

A protocol for managing chance finds developed based on The Historical Monuments Act, 1967 is provided in Box A7.1 below.

Box A7.1: Suggested protocol to manage “chance finds”

1. The contractor shall not perform excavation, demolition, alteration or any works that may harm resources of cultural importance without authorization of the Engineering Assistant or officials from the Department responsible for museums and monuments.

2. In case of chance finds, the Contractor shall mark, cordon and secure the subject site(s) to avoid damage in the course of road construction and immediately notify the Department responsible for museums and monuments.

3. Opening of a new borrow or quarry site shall be witnessed and inspected by official(s) from the Department responsible for museums and monuments for the first 2 days of site opening. The official(s) shall maintain watching briefs during works, with clear procedures for protection and documentation of any “chance finds” encountered (cost of this has been provided in the ESMP, Chapter 8).

4. The contractor is obliged to provide for and ensure archaeological intervention in case they come across new finds. This involves immediate discontinuation of works and notifying the Department responsible for museums and monuments about any discoveries.

5. “Chance finds” encountered in presence of official(s) from the Department of Museums and Monuments shall be handed to them for transfer to the national museum.

6. “Chance finds” encountered in absence of these official shall be handed over to supervising Engineering Assistant, Environmental Officer or District Engineer who would immediately notify officials of the Department of Museums and Monuments.

7. The Contractor, and supervising engineer shall maintain contact details of the Department of Museums and Monuments to quickly notify it in case chance finds are encountered.

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13 GRIEVANCE MANAGEMENT

13.1 Managing grievances

If any grievances arise during implementation of URMCHIP projects, they should be redressed through a systematic and documentable grievance redress mechanism. The grievance redress mechanism should provide avenues for affected persons to lodge complaints or grievances against the project or contractors during URMCHIP projects. It also should describe procedures, roles and responsibilities for managing grievances and resolving disputes. Every aggrieved person shall be able to trigger this mechanism to quickly resolve their complaints.

Key objectives of the grievance process are supposed to be:

i) Provide affected people with avenues for making a complaint or resolving any dispute that may arise during project implementation; ii) Ensure that appropriate and mutually acceptable corrective actions are identified and implemented to address complaints; iii) Verify that complainants are satisfied with outcomes of corrective actions; iv) Avoid the need to resort to judicial (legal court) proceedings.

If a complaint is not related to construction activities, it should be addressed directly to the medical facility In-Charge.

Based on above objectives, grievance management process is described below:

Step 1: Receipt of complaint

A verbal or written complaint from a complainant will be received by the site supervising engineer and recorded in a complaints log kept on site. Complainants will also report any project related comments to the in-charge of the HF or HC.

Step 2: Determination of corrective action

If in his/her view, a grievance can be solved at this stage, the site supervising engineer will determine a corrective action in consultation with the aggrieved person. Grievances will be logged in, resolved and status reported back to complainants within 5 working days. If more time is needed this will be communicated to aggrieved persons.

Step 3: Meeting with the complainant

The proposed corrective action and timeframe in which it is to be implemented will be discussed with the complainant within 5 days of receipt of the grievance. Consent to proceed with corrective action will be sought from the complainant and witnessed by the area‟s local council chairperson (LC Chairman) and a member of the HMT.

Step 4: Implementation of corrective action

Agreed corrective action will be undertaken by supervising engineer and/or the in-charge of HF/HC within the agreed timeframe. The date of the completed action will be recorded in the grievance log.

Step 5: Verification of corrective action

To verify satisfaction, the aggrieved person will be asked to return and resume the grievance process, if not satisfied with the corrective action.

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13.2 Composition of Grievance Committee for COVID-19 and EVD-CERC

Considering the diversity of local conditions and communities, a grievance committee in each case of EVD outbreak should be formed under aegis of MoH to reflect expectations of all parties, local circumstances and equitable representation of all stakeholders involved. At a minimum however such a committee should include:

. Local chairperson of the community/ village . District Health Officer . District Internal Security Officer . Women representative . Youth representative . A representative of vulnerable/ marginalized groups such as indigenous people.

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14 HEALTHCARE WASTE MANAGEMENT GUIDELINES

Health care waste management (HCWM) is a process to help ensure proper hospital hygiene and safety of health care workers and communities. It includes planning and procurement, construction, staff training and behavior, proper use of tools, machines and pharmaceuticals, proper disposal methods inside and outside the hospital, and evaluation. Its many dimensions require a broader focus than the traditional health specialist or engineering point of view. The stages in HCWM are: production of waste within a hospital ward, segregation of waste, ward storage, onsite transportation and treatment (if any), onsite central storage, offsite transportation, treatment, and final disposal. Dealing with such a comprehensive subject which impacts the construction and functionality of health facilities, can be daunting.

Uganda has inadequate HCWM systems in relation to other resource-poor countries both worldwide and specifically within the sub-Saharan African region. A study to identify strategies for improving HCWM, which was conducted in 2003, showed that on average, a hospital generates 0.1 kg of waste/bed/day (excluding pathological waste); a health center (HC) IV generates 1.5 kg of waste /day; a HC III generates 0.6 kg of waste/day; and a HC II generates 0.5 kg of waste /day [1]. However, there is no robust system in place to manage this waste. Poor segregation practices were reported to be highly prevalent and open sharps containers were being used for collection of used needles and syringes. More recent data collected in districts in eastern Uganda show that on average, a district generates 1,000 kg of hazardous waste per month. National surveys on injection and waste management practices conducted in 2003 and 2013 found that health facilities lacked proper trolleys for on-site transportation of waste. The surveys revealed that 44% and 21% of injection providers interviewed had experienced needle-stick injuries in the year prior to the survey in 2003 and 2013, respectively. Incinerators were found in only 2% of the health units.

The recommendations contained in The Health Workers Guide Second Edition 2013 shall be applied in all health facilities in the country. In situations where all recommendations cannot be immediately applied due to financial or institutional constraints, guidelines provided in Annex 8 shall be implemented. The project shall ensure that health workers are trained and provided waste segregation supplies including bins, bin liners, and safety boxes in participating HCFs. In conclusion, with proper planning, targeted interventions can greatly improve HCWM practices.

At each facility there will be a designated individual for HCWM, and this officer will be incorporated into existing QIT where applicable. In absence of such teams, a working group responsible for implementation of the HCWM plan will be established and trained on HCWM.

14.1 Overview of prevailing conditions At the time of preparation of this ESMF, key findings below were made at several health centers

a) Onsite facilities

Many health centers in Uganda dispose of waste by combustion in masonry kilns where medical waste is burnt on a metal grate. These kilns characteristically lack provision of emissions scrubbing and hence largely simply turn a solid waste problem to an air pollution challenge. Inability to reach combustion temperatures higher than 1200oC at which dioxins are known to be destroyed, the kilns are a chronic source of dioxins and other polyaromatic hydrocarbons (PAHs) which are cancer-causing (carcinogenic).

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Plate 1: This masonry kiln “incinerator” at Kamion Health Center II was poorly designed and its construction was never completed.

b) Centralized disposal facilities

It is difficult to find a local government (district) in Uganda that has a centralised medical health disposal facility, either an incinerator or secure landfill. This is the reason waste is disposed of, often inappropriately, on premises by burial (placenta pits) or combustion in masonry kilns or open air burning. c) Onsite healthcare waste management practices

Red Bin Yellow Bin Black Bin

Plate 2: Collecting healthcare waste in open wrongly labeled containers is a common problem at rural health centers

Waste segregation is still a major challenge for especially rural health centers. While color coding is theoretically known by healthcare staff, often waste ends up collected in wrongly color-coded containers. For example the In- Charge of Serere Health Center IV explained that, dangerous waste is put in RED bins, Food waste in YELLOW bins and stationery waste in BLACK bins but as you seen in above picture (Plate 2) two of the three containers bins had similar colors in spite of the signs on the tiled wall indicating RED, YELLOW and BLACK respectively. Collecting medical waste in open containers is not only unsightly but also a public health and occupational risk.

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d) Medical waste contractors

Specialist medical waste contractors having technical know-how, safety gear and appropriate equipment for collection, transportation and disposal of healthcare waste are rare in Uganda. This deficiency is even graver for healthcare facilities located in rural areas. Therefore the common practice at health centers is for waste to be managed by facility‟s staff who often lack awareness about potential risks, necessary safety gear and potency of some medical waste streams.

e) Linkage with HCWM guidelines

i) Approaches to Health Care Waste Management (HCWM), Health Workers Guide, Second Edition (2013); ii) Uganda National Infection Prevention and Control Guidelines (December 2013); iii) National Policy on Injection Safety and Health Care Waste Management (2014).

These documents shall guide management of HCW at facilities constituting this project. According to the proposed project, implementation to this effect shall be through:

. Provision of service standards/protocols for health care waste management (HCWM) under Component 2‟s “Improved quality of care and supervision”, . Implementation of the medical waste management plan, . Training health workers in healthcare waste management

14.2 Practical guidelines for management of each class of healthcare waste

Key principles of good health care waste management that will be followed during project implementation are:

. Minimizing waste at purchasing and point-of-service delivery stage . Segregation of hazardous from non-hazardous HCW . Adequate packaging, handling, and safe storage of all waste categories . Safe, appropriate transportation . Proper treatment of hazardous waste . Appropriate final disposal.

Simple easy to follow guidelines for proper management of each class of waste are outlined Annex 8.

The following HCWM recommendations adopted from: “Approaches to Health Care Waste Management (HCWM): The Health Workers Guide Second Edition 2013” will be implemented, as follows:

A. The District Health Officers

The DHOs will: a) Put in place arrangements to make sure that infectious health care waste/hazardous waste is not mixed with general waste destined for public landfills. These are set out in summary in tables 7 & 8 below b) Participate in the formulation for HCWM plan activities proposed for health facilities in their areas of jurisdiction

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c) Ensure that coordination, monitoring, and reporting on implementation of the HCWM plan is exercised by the HCWM Committee d) Support facilities to implement their HCWM plan e) Set up periodic training programs in all health facilities to ensure that adequate training on HCWM is given to all staff f) Coordinate and monitor all disposal operations, and for this purpose meet regularly with the concerned representative of the local council.

Table 12: Health Facility/Health Post (Rural)

Activities Short Term Solution (up to 2 Long Term Solution (beyond 2 months) months) 1. Segregation  Waste labeling Three-bin system  Three-bin system 2. Collection Health facility based Health facility based 3. Storage On-site storage room On-site storage room 4. Transportation Wheel barrow/trolley Trolley On-site transport Bucket 5. Treatment  Brick type incinerator/small-scale  De Montfort Incinerator incinerator (SSI)  Brick type incinerator  HLD  Double chamber  Autoclave/steam for highly  Autoclave/steam sterilizer for infectious waste and reusable highly infectious waste and reus- items able items 6. Disposal  Encapsulation  Incinerator (see above) (For all category of wastes)  Secured pit burial  Ash pit  Ash pit   Pit burial  Placenta pit  Needle pit

Table 13: Health Facility/Health Post (Urban)

Activities Short Term Solution (up to 2 months) Long Term Solution (beyond 2 months) 1. Segregation Waste bin labeling Three-bin system 2. Collection Health facility based collection  Health facility based

3. Storage Puncture resistant container  Metallic or plastic receptacle  Interim storage room 4. Transportation  Wheel barrow  Trolley On-site transport  Buckets  Car Offsite  Motorcycle/car 5. Treatment  SSI  SSI at/near HC or hospital  Drum incinerator  Drum incinerator at/near HC  Chemical sterilizer or hospital 6. Disposal  Ash pit  Incinerator (For all category of wastes)  Needle pit  Ash pit  Pit burial  Placenta pit

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B. Development and Implementation of a Health Care Waste Management Plan

Each HCW-generating facility shall develop a comprehensive waste management plan as part of the comprehensive HF plan. The HF waste management plan shall be guided by the National HCWM Strategic Plan and HCWM Guidelines. The HCWM plan shall: i) Spell out duties and responsibilities for each management level and different categories of HF staff members. The roles and responsibilities shall be accompanied by SOPs. ii) Contain an estimation of the quantities of HCW generated and the annual budgets for the implementation of the HCWM procedures/plan iii) Contain monitoring procedure to track day-to-day activities of the HF and ensure that HCWM rules are adhered to by all staff iv) Contain information on procedures, location of bins, and storage at strategic points v) Contain budgets for training of all categories of HF staff, including newly recruited health workers vi) Contain budgets for emergency storage and disposal of hazardous HCW in the event of a breakdown of the incinerators or autoclave, and in cases of emergencies as in epidemic outbreaks/epidemics.

Do’s and Don’ts:

1. DO ensure that a good system is in place for segregating different types of waste and that each type is disposed of in an appropriate and safe way. 2. DO train all levels of health care staff (administrators, doctors, nurses, cleaning staff, lab. technicians and engineers) to help ensure that the materials and methods chosen are used correctly and consistently. 3. DO vaccinate all workers who come into contact with HCW against hepatitis B virus. 4. DO monitor costs throughout project implementation in order to determine whether projections are correct and to provide data for better future cost estimates. 5. DO make reasonable adjustments to the project when monitoring progress and costs. 6. DO be realistic. Many countries want the very best and latest technology but don‟t have the necessary resources for sustained use. Proper HCWM can be viewed as a step-wise process, with gains made every few years. The most important goal is to ensure the health and safety of health care workers and the local community. 7. DON’T forget to engage hospital staff in HCWM decisions. Normally, as a HCWM progresses, staff will begin offering serious and substantive advice and ideas for improvement within local constraints. 8. DO consider and consult with the local community.

Project acceptability within the local community is key and project managers need to get early advice and understand socio-economic factors and local concerns. Communities can become surprisingly emotional about HCWM, especially if it touches on cultural biases regarding various types of waste. It is important to address these issues seriously and resolve any concerns quickly: a project that might be viewed as a success internally could be viewed negatively by the community.

14.3 Linkage with HCWMP and strengthening infection control at healthcare facilities The project will deliver some of the requirements of the HCWMP and enable strengthening of infection control at healthcare facilities. This will be achieved through training of healthcare staff in proper waste segregation by types, proper containerization or temporary storage before disposal and disposal as required by national guidelines. This training shall also impart skills necessary for healthcare staff to supervise services of independent /private medical waste contractors hired by health facilities.

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14.4 General HCWM Interventions 14.4.1 Existing situation

MoH has substantial experience in managing medical waste in compliance with Uganda's national environmental requirements, and experience with World Bank‟s safeguards gained from the implementation of existing IDA projects. However, many health facilities still face significant challenges with management of health care waste, ranging from lack, malfunctioning, dilapidated, or out-of-service infrastructure and lack of records on HCWM. Component 2 of the project shall support health facilities that identify needs and priorities for HCWM infrastructure and improvement of processes.

MoH has a health workers guide for HCWM, which will be made available to all facilities under the project. In addition, this ESMF which provides guidance on HCWM (Appendix 9) will also be made available to participating healthcare facilities.

14.4.2 Criteria on HCWM for selecting participating healthcare facilities

HCWM shall be part of the selection criteria for participating health facilities. Selected facilities will have adequate facilities, know-how, staff and commitment to ensure proper HCWM. Therefore to qualify for participation, as a minimum, the HC facility shall have:

. A well-designed, properly constructed placenta pit (if facility has maternity ward) . An incineration unit (built in masonry refractory blocks, or of any other suitable type)

It is expected that with financial resources healthcare facilities get, they should be able to properly manage HCW including infection control through measures below:

. Use of stainless trolleys for healthcare waste movement instead of wheelbarrows . Use of proper protective gear by personnel handling medical waste . Procurement of waste collection containers in case there is delay in receipt of ones supplied by National Medical Stores (NMS)

14.4.3 Interventions planned by the project

Under Component 2, the project will issue service standards/protocols including on health care waste management (besides ones on maternal and perinatal death audits). Training to build capacity in proper HCWM will be provided for staff of participating healthcare facilities. Each participating site shall develop a HCWM-Plan which shall be reviewed by IDA before implementation. It is noted that the project will build new HCW management facilities and where necessary refurbish the dilapidated waste pits, incinerators and placenta pits.

14.5 EVD & COVID-19 medical waste guidelines Managing healthcare waste from EVD & COVID-19 emergency operations should follow both Uganda SOPs and WHO guidelines.

Safe handling, treatment and disposal of health-care waste (HCW) are important tasks within the broader activities of stopping and managing the Ebola and COVID-19 outbreaks. This is especially true considering the large amount of waste generated, including disposal Personal Protective Equipment (PPE). A guide for safe handling of EVD healthcare waste and COVID-19 likewise is provided in Annex 14 with key attributes being:

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a) Main considerations in managing health-care waste

A detailed HCW management plan should be developed during the design of Ebola and COVID-19 treatment facilities. This plan should detail written procedures for healthcare waste management, the number of staff required and their roles and responsibilities. The plan should also detail the safe movement of waste from points of generation, internal transport routes, storage, treatment facility, and final disposal (burial) areas. In addition, the plan should detail supplies needed including personal protective equipment (PPE), sharps containers, waste bins and bags, cleaning supplies and type and capacity of waste treatment technology. The HCW management plans shall consider key principles of waste minimization, reuse and recycling, by requiring HCF to institute practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety. In addition the HCW management plans shall promote waste segregation, packaging, color coding and labeling and require HCF to strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes shall be followed. b) Training for healthcare waste workers

All staff handling EVD & COVID-19 healthcare waste, such as clinicians, cleaners and waste workers, should undergo training regarding waste flow within Ebola treatment facilities and waste separation and disposal. In addition, those tasked with transport, storage and destruction of waste should be trained in proper procedures and how to operate and maintain waste treatment technology. Waste workers should be trained in proper handwashing techniques and have access to alcohol based hand rubs or soap and water according to WHO requirements. c) Storage and transportation of EVD and COVID-19 healthcare waste

Infectious EVD and COVID-19 solid waste should not be transported in bags by hand due to risk of accident or injury from infectious material or incorrectly disposed sharps. Therefore use of a covered trolley should reduce this exposure risk. In facilities where use of such items are difficult due to a lack of concrete or level flooring, a wheelbarrow may be used. If none of these is available, a labelled and lidded puncture resistant collection bin can be carried. After each use, all surfaces of the transport containers should be disinfected with 0.5 % chlorine solution. Ideally, waste should not be stored more than 24 hours before being destroyed. If this is not possible, measures should be taken to provide sufficient staff and materials for regular (even basic) incineration. Onsite collection and transport of COVID-19 wastes shall be adopted including procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF‟s storage area for disposal within 24 hours and proper maintenance and disinfection of the storage areas carried out. d) Important items to consider in disinfection

Live all viruses, EVD virus is relatively fragile and cannot stay for long in harsh external conditions. Ebola and COVID-19 can be rapidly inactivated by various chemical disinfectants. A 0.5% chlorine solution is an effective disinfectant for waste containers, re-usable PPE and other supplies used in managing HCW. Disinfection of tools and spaces pertaining to COVID-19 shall be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners shall be ensured at all times.

e) Possible options for treating EVD and COVID-19 healthcare waste

The most common type of EVD and COVID-19 waste destruction is incineration. The advantage of incineration is that it rapidly reduces the volume of waste while decontaminating materials by burning at high temperatures. Different technologies are available and are generally categorized into low-level, medium-level and advanced incineration. It is not recommended to transport untreated infectious waste and therefore all waste should be treated on-site. Low-level

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incinerators, or burning within an open barrel or pit, serve the immediate need of destroying infectious waste and eliminating Ebola risks. However, such incinerators should be viewed as transitional as waste may not be fully burned. Medium-level and advanced incineration reach higher temperatures for longer periods, hence ensuring complete combustion and elimination of risks associated with EVD and COVID-19 medical waste but require temperature monitoring and air pollution control devices. Autoclaving (use of pressure steam) is a safer and more environmentally friendly alternative to incineration. WHO supports and recognizes the environmental health benefits of using autoclaves for destroying health care waste and has been calling for the phase out of incineration since 2004. All waste, including ashes from burned matter, should be disposed of in pits. The following options shall be considered at the currently 3 designated Hospitals to handle COVID-19 cases (Entebbe Regional Referral Hospital, Naguru Regional Referral Hospital and Mulago National Hospital. The other 14 Regional Referral Hospitals are currently undergoing training to handle COVID-19 cases and shall be operational with effect from March 28, 2020. The following guidance shall be observed at each COVID-19 designated HCF:

. Onsite waste treatment and disposal (e.g. an incinerator): With the exception of Mbarara Regional Referral Hospital, all the COVID-19 designated hospital have their own waste incineration facilities installed onsite. Due diligence of these existing incinerators shall be conducted to examine their technical adequacy, process capacity, performance record, and operator‟s capacity. In case any gaps are discovered, corrective measures shall be recommended. For new HCF financed by the project such as Mbarara Regional Referral Hospital, waste disposal facilities should be integrated into the overall design and ESIA developed. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerator can be found in pertaining EHS Guidelines and GIIP. . Transportation and disposal at offsite waste management facilities: Not all HCF have adequate or well- performing incinerators onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or private sector may be needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities shall be conducted to examine their technical adequacy, process capacity, performance record, and operator‟s capacity. In case any gaps are discovered, corrective measures shall be recommended and agreed with the government or the private sector operators. . Wastewater treatment: HCF wastewater is related to the hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and proper operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, shall be properly disposed of as well. There‟re also cases HCF wastewater may be transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance shall be conducted.

14.6 Emergency Preparedness and Response Emergency incidents which may occur in HCF include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, community, HCF‟s operation and the environment. Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP include the following, as appropriate: (a) engineering controls (such as containment, automatic alarms, and shutoff systems) proportionate to the nature and scale of the hazard; (b) identification of and secure access to emergency

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equipment available on-site and nearby; (c) notification procedures for designated emergency responders; (d) diverse media channels for notification of the affected community and other stakeholders; (e) a training program for emergency responders including drills at regular intervals; (f) public evacuation procedures; (g) designated coordinator for ERP implementation; and (h) measures for first-aid, restoration and cleanup of the environment following any major accident.

14.7 Monitoring and Reporting

Many HCFs face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. HCFs are encouraged to develop an IT based information management system. The Overall in-charge at each HCF shall take overall responsibility for HCW management, lead an intra-departmental team and regularly review issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing system should be in place. Externally, reporting shall be conducted on a monthly and quarterly basis by HCFs to Ministry of Health and World Bank, respectively.

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15 ESMF IMPLEMENTATION BUDGET

The quantities, specifications and estimated costs of design measures to avoid or mitigate negative impacts of each project component site will be assessed by the civil design consultants together with their socio-environmental specialist and incorporated into bidding documents. The contractor will execute all required works and reimbursed through pay items in the bill of quantities financed by the project.

Table below shows a budget breakdown of the cost for implementing the ESMF.

Table 14: Budget estimate for implementing the ESMF

Item Cost Estimate (US $) Notes 1 Mitigation action required during 400,000 Control of erosion, dust, drainage impacts Renovations/repairs/ construction of and construction waste management new health centers. 2 Budget for position of Environmental 180,000 Budgeted at USD3000 gross monthly salary Health Specialist. for 5 years 3 Improvement of HCW management 200,000 Lumpsum cost for entire project through support to implementation of the national health care waste plan (including training, preparation of the HF HCWM plans). 4 Supervision and monitoring by 200,000 Budget based on monitoring plan below: district officers (responsible for social and environment affairs). . 10 Districts sampled per monitoring quarter . USD 1000 per district per quarter as total expenses for all staff involved. . 20 Quarters in 5 years (hence total: 10 Districts x 20 Quarters x USD1000) 5 Training of health workers on HCWM 320,000 Training of Health Workers in proper HCWM and and strengthening infection control World Bank Safeguards (assuming an average of at health facilities. USD80,000 per region) 6 Renovation of existing healthcare To be part of contractors‟ assessment and price waste facilities. quote 7 Lumpsum support for purchase of 400,000 Cost for all four regions HCW containers. 8 Social and environmental 250,000 For medical staff and community sensitization in sensitization and training for Ebola-prone districts and management of EVD communities and medical staff about related waste. Ebola control, and management of medical waste associated with EVD. 10 Social and environmental 250,000 For medical staff and community sensitization in sensitization and training for and management of COVID-19 and related communities and medical staff about environmental and social impacts. COVID-19 control, and management of medical waste associated with COVID-19. TOTAL (US$) 2,200,000

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16 CONCLUSION

This ESMF describes the proposed project, identifies generic and/or likely social and environmental impacts and proposes management measures to control socio-environmental effects during project implementation.

Activities funded under COVID-19 and Ebola CERC will remain relevant for emergency response and include: detection of all suspected cases and collect samples for laboratory confirmation; identification and tracking of all EVD contacts; organization of medical and psychosocial case management including nutritional support; reducing the risk of transmission of EVD in the community; strengthening infection prevention and control measures at health facilities; strengthening surveillance in health districts vulnerable to transmission of EVD because of population movement; strengthening community mobilization through participatory communication on social, behavioral change, and local community engagement and participation; immunization of at‐risk groups (front‐line staff, case contacts, and contact of contacts); and free care to all infected health areas. All these activities are core interventions for a response to EVD outbreak. No changes are envisioned with regard to implementation arrangements of CERC by the Ministry of Health (MOH). Implementation of CERC-IP will follow CERC operations manual and the Standard Operating Procedures (SOP) prepared to support EVD preparedness and response activities. CERC Implementation Plan (CERC-IP) is a subset of the National Contingency Emergency Response Plan for Ebola and will focus on the most urgent short-term needs for Ebola response over the next 12 months which are not financed by other sources. Financing of Ebola CERC will put Uganda in good stead to enable preparedness and ability to effectively handle EVD emergency response in case of an outbreak.

ESMP should be developed at ESIA stage of project facilities where this is necessary. Involvement of existing institutional structures and training is important especially for impact monitoring. For this reason capacity building of Ministry of Health‟s Environmental Health Division (EHD), District Local Governments and Health Facility staff is recommended to ensure they are effective in monitoring not only construction activities but also associated operation phase socio-environmental impacts as provided in this ESMF.

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Bibliographies

1. Approaches to Health Care Waste Management, Health Workers Guide, Second Edition (2013), 2. National Health Care Waste Management Plan (2009/2010 – 2011/2012) 3. National Policy on Injection Safety and Health Care Waste Management (20014). 4. NEMA (2009), “Uganda: Atlas of Our Changing Environment.” National Environment Management Authority (NEMA) 5. NEMA, 2009: Sensitivity Atlas for Albertine Graben. 6. Population Secretariat (2010). Uganda: Population Factors & National Development. Kampala Uganda 7. Sansa. A, 2005: relationship between indoor air pollution and acute respiratory infections among children in Uganda. Workshop, Tanzania, January 2005. 8. The Land Act 1998 9. The National Environment Act, Cap 153. 10. The Public Health Act, Cap 281 11. The Water Act Cap 152 12. The Water Resources Regulations 1998 13. Uganda National Infection Prevention and Control Guidelines (Dec 2013), 14. Vaughn L.M, Jacquez. F. and C. Baker. R.C, 2009. Cultural Health Attributions, Beliefs, and Practices: Effects on Healthcare and Medical Education The Open Medical Education Journal, 2009, 2, 64-74 15. Baggi FM, Taybi A, Kurth A, et al. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Eurosurveillance. 2014;19(49). 16. Bossi P, Tegnell A, Baka A, et al. Bichat Guidelines for the clinical management of haemorrhagic fever viruses and bioterrorism-related haemorrhagic fever viruses. Euro Surveill. 2004;9(12):E11-E12. (Practice guidelines) 17. Centers for Disease Control and Prevention. 2014 Ebola outbreak in West Africa. Available at: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html. Accessed November 19, 2019. 18. Centers for Disease Control and Prevention. Considerations for discharging persons under investigation (PUI) for Ebola virus disease (Ebola). Available at: http://www.cdc.gov/vhf/ebola/healthcare-us/evaluating- patients/discharging.html. Accessed November 20, 2019. 19. Centers for Disease Control and Prevention. Ebola (Ebola virus disease): diagnosis. Available at: http://www.cdc.gov/vhf/ebola/diagnosis/index.html. Accessed February 23, 2015. (Website) 20. Centers for Disease Control and Prevention. Epidemiologic risk factors to consider when evaluating a person for exposure to Ebola virus. Available at: http://www.cdc.gov/vhf/ebola/exposure/risk-factors-when-evaluating- person-for-exposure.html. Accessed November 20, 2019. 21. Chertow DS, Kleine C, Edwards JK, et al. Ebola virus disease in West Africa--clinical manifestations and management. N Engl J Med. 2014;371(22):2054-2057. 22. Dixon MG, Schafer IJ. Ebola viral disease outbreak--West Africa, 2014. MMWR Morb Mortal Wkly Rep. 2014;63(25):548- 551. (CDC Report) 23. Feldmann H. Ebola--a growing threat? N Engl J Med. 2014;371(15):1375-1378. 24. GoU, WHO, UKAID 2015: Standard Operating Procedures and Guidelines for Responding to Ebola/Marburg Virus Disease Outbreaks in Uganda. A Guide for National Response. 25. Government of Sierra Leone Ministry Of Health and Sanitation 2014: Sierra Leone Accelerated Ebola Virus Disease Outbreak Response Plan. 26. IDSA Ebola Guidance. Guidelines/patient care - emerging clinical issues. Available at: http://www.idsociety.org/2014_ebola/. Accessed November 18, 2019. 27. Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. J Infect Dis. 2011;204 Suppl 3:S810-S816. (Review) 28. Leroy EM, Baize S, Lu CY, et al. Diagnosis of Ebola haemorrhagic fever by RT-PCR in an epidemic setting. J Med Virol. 2000;60(4):463-467. (Prospective; 51 patients) 29. Martin P, Laupland KB, Frost EH, et al. Laboratory diagnosis of Ebola virus disease. Intensive Care Med. 2015. (Review)

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30. MoH & USAID, 2009: Making medical injections safer (MMIS) Project Approaches to healthcare waste management (Health Workers Guide). 31. Mupere E, Kaducu OF, Yoti Z. Ebola haemorrhagic fever among hospitalised children and adolescents in northern Uganda: epidemiologic and clinical observations. Afr Health Sci. 2001;1(2):60-65. 32. Roddy P, Colebunders R, Jeffs B, et al. Filovirus hemorrhagic fever outbreak case management: a review of current and future treatment options. J Infect Dis. 2011;204 Suppl 3:S791- S795. (Review) 33. Uganda MoH 2019: Ebola Virus Disease in Uganda: Situation Report SitRep #07 34. Uganda Simulates Ebola Outbreak and Identifies Gaps in Preparedness and Response (World Health Organization Report Published on 24 Apr 2019. Accessed 20Nov2019 from: https://reliefweb.int/report/uganda/uganda-simulates-ebola-outbreak-and-identifies-gaps-preparedness-and- response) 35. WHO & UNICEF, 2014: Ebola virus disease: Key questions and answers concerning health care waste. 36. WHO & UNICEF, 2014: Ebola virus disease: Key questions and answers concerning water, sanitation and hygiene 37. WHO Ebola Response Team. Ebola virus disease in West Africa--the first 9 months of the epidemic and forward projections. N Engl J Med. 2014;371(16):1481-1495. 38. World Health Organization. One year into the Ebola epidemic: a deadly, tenacious and unforgiving virus. Available at: http://www.who.int/csr/disease/ebola/one-year-report/ebola-report-1-year.pdf?ua=1. (Accessed February 9, 2015). 39. “The World Bank, 2018. Environment and Social Incident Response Toolkit for World Bank Staff. 40. Ministry of Health (MoH), 2020: The Do‟s And Don‟ts On Corona Virus Disease (COVID-19). 41. Bank of Uganda, 2020: Measures to mitigate economic impact of COVID-19. 42. Uganda braces for economic impact of COVID-19. (Source: http://www.xinhuanet.com/english/2020- 03/20/c_138898637.htm Accessed: 23 March 2020).

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Annexes Annex 1: Screening form for potential Environmental & Social Safeguards (ESSF)

This form is to be used by the Implementing Agency for to screen potential environmental and social environmental and social risk levels of a proposed subproject, determine the relevance of Bank environmental and social standards (ESS), propose its E&S risk levels, and the instrument to be prepared for the sub project. Subproject Name

Subproject Location

Subproject Proponent

Estimated Investment

Start/Completion Date

Questions Answer Relevant ESS Due diligence / Yes No Actions Does the subproject involve civil works including new ESS1 ESIA/ESMP, SEP construction, expansion, upgrading or rehabilitation of healthcare facilities and/or associated waste management facilities? Does the subproject involve land acquisition and/or ESS5 RAP/ARAP, SEP restrictions on land use? Does the subproject involve acquisition of assets to hold ESS5 patients (including yet-to-confirm cases for medical observation or isolation purpose)? Is the subproject associated with any external waste ESS3 ESIA/ESMP, SEP management facilities such as a sanitary landfill, incinerator, or wastewater treatment plant for healthcare waste disposal? Is there sound regulatory framework, institutional capacity ESS1 ESIA/ESMP, SEP in place for healthcare facility infection control and healthcare waste management? Does the subproject involve recruitment of workforce ESS2 LMP, SEP including direct, contracted, primary supply, and/or community workers? Does the subproject involve transboundary transportation ESS3 ESIA/ESMP, SEP of specimen, samples, infectious and hazardous materials? Does the subproject involve use of security personnel ESS4 ESIA/ESMP, SEP during construction and/or operation of healthcare facilities? Is the subproject located within or in the vicinity of any ESS6 ESIA/ESMP, SEP ecologically sensitive areas? Are there any vulnerable groups present in the subproject ESS7 Vulnerable Groups area and are likely to be affected by the proposed Plan/IPDP subproject negatively or positively? Is the subproject located within or in the vicinity of any ESS8 ESIA/ESMP, SEP known cultural heritage sites? Does the project area present considerable Gender-Based ESS1 ESIA/ESMP, SEP Violence (GBV) and Sexual Exploitation and Abuse (SEA) risk? P a g e | 100

Questions Answer Relevant ESS Due diligence / Yes No Actions Is there any territorial dispute between two or more OP7.60 Projects in Governments countries in the subproject and its ancillary aspects and Disputed Areas concerned agree related activities? Will the sub project and its ancillary aspects and related OP7.50 Projects on Notification activities involve the use or potential pollution of, or be International (or exceptions) located in international waterways31? Waterways

Conclusions:

1. Proposed Environmental and Social Risk Ratings (High, Substantial, Moderate or Low). Provide Justifications.

2. Proposed E&S Instruments.

31 International waterways include any river, canal, lake or similar body of water that forms a boundary between, or any river or surface water that flows through two or more states.

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E. PROJECTS TO HAVE MANDATORY ESIA ACCORDING TO THE NATIONAL ENVIRONMENT ACT, No.5, 2019

Excerpt of Section 5 of Fifth schedule of The National Environment Act, No.5, 2019

5. Housing and urban development.

(a) Construction of planned settlements or housing estates covering at least 5 acres. (b) Establishment or expansion of development zones, industrial estates and industrial parks. (c) Construction and expansion of public and private hospitals. (d) Construction and expansion of educational and research institutions. (e) Shopping centres and other commercial complexes covering a floor area of 2500/10,000m2 or more. (f) Construction of warehouses. (g) Support facilities to (a) to (f).

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Annex 2: Environment and Social Mitigation Measures Checklist A sample checklist is provided below to guide development of mitigation measures during implementation. It should be noted that this checklist is to be used as a guide and full details of mitigation measures shall be documented in the ESIA/ESMP/contract documents.

Activity: Environmental Nature of environmental Required action /mitigation Construction of health component affected concern measure by Contractor centers 1. Burning of Soil Soil erosion. Sensitize community Brick Geology Dumping of soil waste Tree planting Brick making Vegetation material Cover pits Firewood Uncovered pits Burning of bricks pollution 2.Site Leveling Soil Erosion and Restore the borrow areas with Excavations in borrow Human beings sedimentation topsoil areas. Animals Geology Labor accidents. Proper grading of the sites at Grading to attain Plants Silting. the right camber right camber Creates ponds that Provide first aid kits. encourage breeding of Soil bunds should be mosquitoes constructed around a single designated area 3. Building Human beings Noise Constructors‟ Dress Accidents First aid Kits Dust Protective gear 4. Roofing Human beings Accidents Protective gear First aid Kits 5. Soak pits, septic Human beings Contaminated water Community consultation. tanks and disposal Land Land acquisition Consult with DEO for fields Water Disease outbreak appropriate siting of waste Accessibility of the waste collection point. bins, collection points Provide adequate waste collection bins Conduct hygiene education campaign. 6. Waste pits Vegetation Contamination of ground (including ones for Soil water supply sources through hygiene practices after using the disposal of ashes Surface water subsurface flow of human latrine e.g. washing their hands. from EVD Human beings waste. healthcare waste Contamination of surface latrines, which can be emptied. incineration) water sources through Consider constructing water transportation by storm borne squat toilets if there is piped runoff. water in the school. Flies and rodents carrying disease from latrine. More land is used in construction of new latrines when old ones fill up.

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Annex 3: Sample Terms of Reference for EIA

In case an EIA has to be undertaken for any specific project component or facility, the MoH will procure the services of a certified NEMA EIA Practitioner to undertake the EIA study. The following will be the content of the ToR‟s for this study.

Introduction and Context This part will be completed at a time and will include necessary information related to the context and methodology to carry out the study. It will briefly describe the purpose and objectives of the project, and the specific facility for which the EIA is undertaken.

Objectives of EIA study

. To identify all likely positive and negative environmental impacts due to the specific project; . To identify and evaluate all significant negative environmental impacts, and propose appropriate mitigation measures for the attention of the developer, for incorporation into the final construction and operational phases; . To propose an environmental management plan for all aspects of the specific project.

EIA study tasks

The consultant should realize the following:

. Describe the project characteristics, including extent, land requirement, material requirements, construction works, and the beneficiary community; . Describe the biophysical characteristics of the environment where the project activities will be realized; and underline the main constraints that need to be taken into account at the field preparation, construction works and future school or project operations; . Assess the potential environmental and social impacts related to project activities and recommend adequate mitigation measures, including costs estimation. . Review alternative more cost-effective and environmentally and socially friendlier options for achieving the same objectives, . Review policy, legal and institutional framework, at national and international level, related to the environment and identify the constraints for best practices in management with appropriate recommendations for improvements, . Identify responsibilities and actors for the implementation of proposed mitigation measures, . Assess the capacity available to implement the proposed mitigation measures, and suggest recommendations in terms of training and capacity building and estimate their costs, . Develop an Environmental Management Plan (EMP) for the project. The EMP should underline (i) the potential environmental and social impacts resulting from project activities (ii) the proposed mitigation measures; (iii) the institutional responsibilities for implementation; (iv) the monitoring indicators; (v) the institutional responsibilities for monitoring and implementation of mitigation measures; (vi) the costs of activities; and (vii) the implementation schedule, . Public consultations: The EIA results and the proposed mitigation measures will be discussed with populations, NGOs, local administration and other stakeholders impacted by the project activities. Recommendations from this public consultation will be include in the final EIA report.

Structure of the EIA Report

. Cover page . Table of contents . List of acronyms . Executive summary . Introduction . Description of project activities . Description of environment in the project area . Description of policy, legal and institutional framework . Presentation of results of public consultations and disclosure, and proposed social action by the developer; . Description of methodology and techniques used in the assessment and analyses of project impacts,

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. Description of environmental and social impacts of project activities, . Environmental Management Plan (EMP) for the project including the proposed mitigation measures; the institutional responsibilities for implementation; the monitoring indicators; the institutional responsibilities for monitoring and implementation of mitigation; Summary table for EMP . Recommendations . References . List of persons / institutions met

Consultant team

The Consultants will be NEMA -Certified EIA Practitioners or others agreed by NEMA.

Typical construction impacts

Typically impacts of construction projects arise from sourcing materials and what is generated after they are used (construction waste) as illustrated below.

Typical impacts are outlined in table below.

Action Impact Mitigation 1 Change of Landuse. . Direct Impact – On the plot of land . Restrict development to school . Indirect Impact – On neighboring plots. land. . Cumulative Impact – On the . Ensure development is permitted surrounding area which will gradually by local physical planning office. change. 2 Clearing of vegetation. . Soil erosion . Minimise vegetation clearing by . Dust emissions restring activity to building footprint, as much as possible.

. Revegetate cleared areas as quickly as practicable. . Ensure proper site drainage 3 Material transportation. . Accidents risk to school children. Schedule this to be before or after . Road dust. school hours.

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. Traffic noise at school campus.

4 Building activities. Construction noise. Schedule noisy activities to be outside school hours. 5 Risk of falling debris to Accident to children. Fence off construction site to avoid children. access by children. 6 Waste management Illegal dumping of waste in unauthorized . Ensure waste disposal is done places leading to contamination or with guidance of local grievances by property owners. environment officer‟s guidance and authorization. . Stripped soil (overburden) should be used for site restoration/ landscaping, rather than being dumped offsite. . Workers should not liter school campus with litter (plastic bags, water bottles, etc). . Reusable waste (e.g. timber planks, paper bags, etc) should be given to local people if requested. . Pit latrines should be lined with masonry brickwork to enable their emptying with a honey sucker when full. 7 Working at heights or . Risk of falls when workers at height . All workers should have depths (e.g. roofs) do not use safety latches. appropriate safety gear . Risk of workers being interred by . Latrines should be safely dug on collapsing earth walls when digging pit firm ground, carefully watching out latrines. for signs of possible wall failure. 8 Material acquisition . Leaving borrow sites unrestored after . Obtain material from already project completion. existing borrow sites and stone quarries. 9 Employment . Local people benefitting from . Contractors should hire atleast 5 construction projects people from the local community at anyone project. 10 Occupational safety . Workers getting buried by collapsing . Pits must never be dug in earth walls when digging pit latrines unstable soils . All workers must have necessary safety gear

Annex 4: Clauses for Construction Work Contracts on Environmental Compliance General Environmental Management Conditions for Construction Contracts General 1. In addition to these general conditions, the Contractor shall comply with any specific Environmental Management Plan (EMP) or Environmental and Social Management Plan (ESMP) for the works he is responsible for. The Contractor shall inform himself about such an EMP, and prepare his work strategy and plan to fully take into account relevant provisions of that EMP. If the Contractor fails to implement the approved EMP after written instruction by the Supervising Engineer (SE)

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to fulfill his obligation within the requested time, the Owner reserves the right to arrange through the SE for execution of the missing action by a third party on account of the Contractor.

2. Notwithstanding the Contractor‟s obligation under the above clause, the Contractor shall implement all measures necessary to avoid undesirable adverse environmental and social impacts wherever possible, restore work sites to acceptable standards, and abide by any environmental performance requirements specified in an EMP. In general these measures shall include but not be limited to:

(a) Minimize the effect of dust on the surrounding environment resulting from earth mixing sites, asphalt mixing sites, dispersing coal ashes, vibrating equipment, temporary access roads, etc. to ensure safety, health and the protection of workers and communities living in the vicinity dust producing activities. (b) Ensure that noise levels emanating from machinery, vehicles and noisy construction activities (e.g. excavation, blasting) are kept at a minimum for the safety, health and protection of workers within the vicinity of high noise levels and nearby communities.

(c) Ensure that existing water flow regimes in rivers, streams and other natural or irrigation channels is maintained and/or re-established where they are disrupted due to works being carried out.

(d) Prevent bitumen, oils, lubricants and waste water used or produced during the execution of works from entering into rivers, streams, irrigation channels and other natural water bodies/reservoirs, and also ensure that stagnant water in uncovered borrow pits is treated in the best way to avoid creating possible breeding grounds for mosquitoes.

(e) Prevent and minimize the impacts of quarrying, earth borrowing, piling and building of temporary construction camps and access roads on the biophysical environment including protected areas and arable lands; local communities and their settlements. In as much as possible restore/rehabilitate all sites to acceptable standards.

(f) Upon discovery of ancient heritage, relics or anything that might or believed to be of archaeological or historical importance during the execution of works, immediately report such findings to the SE so that the appropriate authorities may be expeditiously contacted for fulfilment of the measures aimed at protecting such historical or archaeological resources.

(g) Discourage construction workers from engaging in the exploitation of natural resources such as hunting, fishing, collection of forest products or any other activity that might have a negative impact on the social and economic welfare of the local communities.

(h) Implement soil erosion control measures in order to avoid surface run off and prevents siltation, etc.

(i) Ensure that garbage, sanitation and drinking water facilities are provided in construction workers camps. (j) Ensure that, in as much as possible, local materials are used to avoid importation of foreign material and long distance transportation.

(k) Ensure public safety, and meet traffic safety requirements for the operation of work to avoid accidents.

3. The Contractor shall indicate the period within which he/she shall maintain status on site after completion of civil works to ensure that significant adverse impacts arising from such works have been appropriately addressed.

4. The Contractor shall adhere to the proposed activity implementation schedule and the monitoring plan / strategy to ensure effective feedback of monitoring information to project management so that impact management can be implemented properly, and if necessary, adapt to changing and unforeseen conditions.

5. Besides the regular inspection of sites by the SE for adherence to the contract conditions and specifications, the Owner may appoint an Inspector to oversee the compliance with these environmental conditions and any proposed mitigation measures. State environmental authorities may carry out similar inspection duties. In all cases, as directed by the SE, the Contractor shall comply with directives from such inspectors to implement measures required to ensure the adequacy

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rehabilitation measures carried out on the bio-physical environment and compensation for socio-economic disruption resulting from implementation of any works.

Worksite/Campsite Waste Management

6. All vessels (drums, containers, bags, etc.) containing oil/fuel/surfacing materials and other hazardous chemicals shall be bunded in order to contain spillage. All waste containers, litter and any other waste generated during the construction shall be collected and disposed of at designated disposal sites in line with applicable government waste management regulations. 7. All drainage and effluent from storage areas, workshops and camp sites shall be captured and treated before being discharged into the drainage system in line with applicable government water pollution control regulations.

8. Used oil from maintenance shall be collected and disposed of appropriately at designated sites or be re-used or sold for reuse locally. 9. Entry of runoff to the site shall be restricted by constructing diversion channels or holding structures such as banks, drains, dams, etc. to reduce the potential of soil erosion and water pollution.

10. Construction waste shall not be left in stockpiles along the road, but removed and reused or disposed of on a daily basis. 11. If disposal sites for clean spoil are necessary, they shall be located in areas, approved by the SE, of low land use value and where they will not result in material being easily washed into drainage channels. Whenever possible, spoil materials should be placed in low-lying areas and should be compacted and planted with species indigenous to the locality. Material Excavation and Deposit

12. The Contractor shall obtain appropriate licenses/permits from relevant authorities to operate quarries or borrow areas.

13. The location of quarries and borrow areas shall be subject to approval by relevant local and national authorities, including traditional authorities if the land on which the quarry or borrow areas fall in traditional land.

14. New extraction sites:

a) Shall not be located in the vicinity of settlement areas, cultural sites, wetlands or any other valued ecosystem component, or on high or steep ground or in areas of high scenic value, and shall not be located less than 1km from such areas.

b) Shall not be located adjacent to stream channels wherever possible to avoid siltation of river channels. Where they are located near water sources, borrow pits and perimeter drains shall surround quarry sites.

c) Shall not be located in archaeological areas. Excavations in the vicinity of such areas shall proceed with great care and shall be done in the presence of government authorities having a mandate for their protection.

d) Shall not be located in forest reserves. However, where there are no other alternatives, permission shall be obtained from the appropriate authorities and an environmental impact study shall be conducted.

e) Shall be easily rehabilitated. Areas with minimal vegetation cover such as flat and bare ground, or areas covered with grass only or covered with shrubs less than 1.5m in height, are preferred.

f) Shall have clearly demarcated and marked boundaries to minimize vegetation clearing.

15. Vegetation clearing shall be restricted to the area required for safe operation of construction work. Vegetation clearing shall not be done more than two months in advance of operations.

16. Stockpile areas shall be located in areas where trees can act as buffers to prevent dust pollution. Perimeter drains shall be built around stockpile areas. Sediment and other pollutant traps shall be located at drainage exits from workings.

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17. The Contractor shall deposit any excess material in accordance with the principles of these general conditions, and any applicable EMP, in areas approved by local authorities and/or the SE.

18. Areas for depositing hazardous materials such as contaminated liquid and solid materials shall be approved by the SE and appropriate local and/or national authorities before the commencement of work. Use of existing, approved sites shall be preferred over the establishment of new sites.

Rehabilitation and Soil Erosion Prevention

19. To the extent practicable, the Contractor shall rehabilitate the site progressively so that the rate of rehabilitation is similar to the rate of construction.

20. Always remove and retain topsoil for subsequent rehabilitation. Soils shall not be stripped when they are wet as this can lead to soil compaction and loss of structure.

21. Topsoil shall not be stored in large heaps. Low mounds of no more than 1 to 2m high are recommended. 22. Re-vegetate stockpiles to protect the soil from erosion, discourage weeds and maintain an active population of beneficial soil microbes.

23. Locate stockpiles where they will not be disturbed by future construction activities. 24. To the extent practicable, reinstate natural drainage patterns where they have been altered or impaired.

25. Remove toxic materials and dispose of them in designated sites. Backfill excavated areas with soils or overburden that is free of foreign material that could pollute groundwater and soil.

26. Identify potentially toxic overburden and screen with suitable material to prevent mobilization of toxins. 27. Ensure reshaped land is formed so as to be inherently stable, adequately drained and suitable for the desired long-term land use, and allow natural regeneration of vegetation.

28. Minimize the long-term visual impact by creating landforms that are compatible with the adjacent landscape. 29. Minimize erosion by wind and water both during and after the process of reinstatement. 30. Compacted surfaces shall be deep ripped to relieve compaction unless subsurface conditions dictate otherwise.

31. Revegetate with plant species that will control erosion, provide vegetative diversity and, through succession, contribute to a resilient ecosystem. The choice of plant species for rehabilitation shall be done in consultation with local research institutions, forest department and the local people.

Water Resources Management

32. The Contractor shall at all costs avoid conflicting with water demands of local communities.

33. Abstraction of both surface and underground water shall only be done with the consultation of the local community and after obtaining a permit from the relevant Water Authority.

34. Abstraction of water from wetlands shall be avoided. Where necessary, authority has to be obtained from relevant authorities.

35. Temporary damming of streams and rivers shall be done in such a way avoids disrupting water supplies to communities downstream, and maintains the ecological balance of the river system.

36. No construction water containing spoils or site effluent, especially cement and oil, shall be allowed to flow into natural water drainage courses.

37. Wash water from washing out of equipment shall not be discharged into water courses or road drains.

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Traffic Management

39. Location of access roads/detours shall be done in consultation with the local community especially in important or sensitive environments. Access roads shall not traverse wetland areas.

40. Upon the completion of civil works, all access roads shall be ripped and rehabilitated.

41. Access roads shall be sprinkled with water at least five times a day in settled areas, and three times in unsettled areas, to suppress dust emissions.

Blasting

42. Blasting activities shall not take place less than 2km from settlement areas, cultural sites, or wetlands without the permission of the SE.

43. Blasting activities shall be done during working hours, and local communities shall be consulted on the proposed blasting times. 44. Noise levels reaching the communities from blasting activities shall not exceed 90 decibels.

Disposal of Unusable Elements

45. Unusable materials and construction elements such as electro-mechanical equipment, pipes, accessories and demolished structures will be disposed of in a manner approved by the SE. The Contractor has to agree with the SE which elements are to be surrendered to the Client‟s premises, which will be recycled or reused, and which will be disposed of at approved landfill sites.

46. As far as possible, abandoned pipelines shall remain in place. Where for any reason no alternative alignment for the new pipeline is possible, the old pipes shall be safely removed and stored at a safe place to be agreed upon with the SE and the local authorities concerned.

47. AC-pipes as well as broken parts thereof have to be treated as hazardous material and disposed of as specified above. 48. Unsuitable and demolished elements shall be dismantled to a size fitting on ordinary trucks for transport.

Health and Safety

49. In advance of the construction work, the Contractor shall mount an awareness and hygiene campaign. Workers and local residents shall be sensitized on health risks particularly of AIDS.

50. Adequate road signs to warn pedestrians and motorists of construction activities, diversions, etc. shall be provided at appropriate points.

51. Construction vehicles shall not exceed maximum speed limit of 40km per hour.

Repair of Private Property

52. Should the Contractor, deliberately or accidentally, damage private property, he shall repair the property to the owner‟s satisfaction and at his own cost. For each repair, the Contractor shall obtain from the owner a certificate that the damage has been made good satisfactorily in order to indemnify the Client from subsequent claims.

53. In cases where compensation for inconveniences, damage of crops etc. are claimed by the owner, the Client has to be informed by the Contractor through the SE. This compensation is in general settled under the responsibility of the Client before signing the Contract. In unforeseeable cases, the respective administrative entities of the Client will take care of compensation.

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Contractor’s Health, Safety and Environment Management Plan (HSE-MP)

54. Within 6 weeks of signing the Contract, the Contractor shall prepare an EHS-MP to ensure the adequate management of the health, safety, environmental and social aspects of the works, including implementation of the requirements of these general conditions and any specific requirements of an EMP for the works. The Contractor‟s EHS-MP will serve two main purposes:

 For the Contractor, for internal purposes, to ensure that all measures are in place for adequate HSE management, and as an operational manual for his staff.  For the Client, supported where necessary by a SE, to ensure that the Contractor is fully prepared for the adequate management of the HSE aspects of the project, and as a basis for monitoring of the Contractor‟s HSE performance.

55. The Contractor‟s EHS-MP shall provide at least:  a description of procedures and methods for complying with these general environmental management conditions, and any specific conditions specified in an EMP;  a description of specific mitigation measures that will be implemented in order to minimize adverse impacts;  a description of all planned monitoring activities (e.g. sediment discharges from borrow areas) and the reporting thereof; and  the internal organizational, management and reporting mechanisms put in place for such.

56. The Contractor‟s EHS-MP will be reviewed and approved by the Client before start of the works. This review should demonstrate if the Contractor‟s EHS-MP covers all of the identified impacts, and has defined appropriate measures to counteract any potential impacts.

HSE Reporting

57. The Contractor shall prepare bi-weekly progress reports to the SE on compliance with these general conditions, the project EMP if any, and his own EHS-MP. An example format for a Contractor HSE report is given below. It is expected that the Contractor‟s reports will include information on:  HSE management actions/measures taken, including approvals sought from local or national authorities;  Problems encountered in relation to HSE aspects (incidents, including delays, cost consequences, etc. as a result thereof);  Lack of compliance with contract requirements on the part of the Contractor;  Changes of assumptions, conditions, measures, designs and actual works in relation to HSE aspects; and  Observations, concerns raised and/or decisions taken with regard to HSE management during site meetings.

58. It is advisable that reporting of significant HSE incidents be done “as soon as practicable”. Such incident reporting shall therefore be done individually. Also, it is advisable that the Contractor keep his own records on health, safety and welfare of persons, and damage to property. It is advisable to include such records, as well as copies of incident reports, as appendixes to the bi-weekly reports. Example formats for an incident notification and detailed report are given below. Details of HSE performance will be reported to the Client through the SE‟s reports to the Client.

Training of Contractor’s Personnel

59. The Contractor shall provide sufficient training to his own personnel to ensure that they are all aware of the relevant aspects of these general conditions, any project EMP, and his own EHS-MP, and are able to fulfill their expected roles and functions. Specific training should be provided to those employees that have particular responsibilities associated with the implementation of the EHS-MP. General topics should be:

 HSE in general (working procedures);  emergency procedures; and  social and cultural aspects (awareness raising on social issues).

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HIV/AIDS: The contractors should have an HIV/AIDS policy and a framework (responsible staff, action plan, etc) to implement it during project execution.

Cost of Compliance

60. It is expected that compliance with these conditions is already part of standard good workmanship and state of art as generally required under this Contract. The item “Compliance with Environmental Management Conditions” in the Bill of Quantities covers these costs. No other payments will be made to the Contractor for compliance with any request to avoid and/or mitigate an avoidable HSE impact.

Example Format: HSE Report Contract: Period of reporting: HSE management actions/measures: Summarize HSE management actions/measures taken during period of reporting, including planning and management activities (e.g. risk and impact assessments), HSE training, specific design and work measures taken, etc.

HSE incidents: Report on any problems encountered in relation to HSE aspects, including its consequences (delays, costs) and corrective measures taken. Include relevant incident reports.

HSE compliance: Report on compliance with Contract HSE conditions, including any cases of non-compliance.

Changes: Report on any changes of assumptions, conditions, measures, designs and actual works in relation to HSE aspects.

Concerns and observations: Report on any observations, concerns raised or decisions taken with regard to HSE management during site meetings and visits.

Signature (Name, Title Date): Contractor Representative

Example Format: HSE Incident Notification

Provide within 24 hrs to the Supervising Engineer

Originators Reference No: Date of Incident: Time:

Location of incident:

Name of Person(s) involved:

Employing Company:

Type of Incident:

Description of Incident: Where, when, what, how, who, operation in progress at the time (only factual)

Immediate Action: Immediate remedial action and actions taken to prevent reoccurrence or escalation

Signature (Name, Title, Date): ……………………………..… Contractor Representative

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Annex 5: Record of Consultation

Week Meeting date 31 March 2016 Recorded by Richard Meeting with Kaabong District Health Officials and Kamion HC II Officials on, IPP For Uganda Meeting/subject Total pages 2 Reproductive, Maternal, Neonatal, and Child Health Improvement Project Item Update

1. Introduction The team leader started by introducing himself, the project and purpose of the meeting which was primarily to inquire about health related issues concerning the Ik people in Kaabong district.

Kamion Health Centre II is one of the health centre located in the Ik community.

The DHO welcomed the team and he expressed gratitude to consult the Ik people who for long have been marginalized and seen as minority among the people of the district.

2. Issues discussed Do you have Village Health Team (VHT) in Kaabong District? We have them in all the sub-counties and villages. Are they active in their work? Yes they are active. What common diseases are there among the IK? There are many diseases but the most common ones are, Malaria, Respiratory Tract Infections (RTIs), Diarrhoea, Gastro-interties, eye infections and skin diseases.

Which is the most prevalent but most dangerous? Malaria, Chicken pox, dysentery Are there staff who speak Ik language in health center(s) visited by Ik people? Unfortunately no and Ik people are compelled to use Karamojong language since they are the minority. Do the IK people practice any traditional health practice? Yes for example consulting traditional healers, medicine men/women and foretellers. Do Ik people have culture practices that may be harmful to their health? They copy the practice of the Karamojong for example body tattooing. Are the services provided to the IK very specific or general even to the other communities? No special services are provided to the Ik people. However, services such as safe delivery education are often 2.1. offered, and they (Ik) are also taken as priority at any time, for example they are always attended to 24 hours 7 days a week. Is there any cultural practice that prevents them from seeking medical help? Not many apart from the practice of mothers demanding to keep placentas after birth. What is the staffing of health centre II? It is supposed to be 9 staff; however for our case we have only 3. Do you offer services of Health Centre II or Health Centre III? This is Health CenterII which is meant to offer only out-patient department (OPD). However being the only health centre in the area we offer also other services for health centre III for example, antenatal care (ANC), family planning and deliveries and in-patient (Admission) but with only one bed. Does the community get epidemics and when? We get epidemics especially during wet season when there are many mosquitoes. How does Kamion HC II manage medical waste? Through segregation into different categories since there are different types of waste for example pharmaceutical waste, human excretes, and other waste. Do you have proper waste disposal facilities? No, due to the fact that there is no functional incinerator. How does the HC dispose of unclaimed dead bodies? They are always taken to the hospital cemetery

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Does the HC own a cemetery? No. What do you suggest about the above? I suggest that the local health centre administration should purchase a parcel of land for that purpose. Who owns the land where the health centre located? It was donated by the local community. Is there some encroachment on the health centre land? Yes. How do you manage the land encroachment problem? Through meetings with the health unit management committee and the encroaching people so that we reach a mutual agreement. Generally, what are the challenges faced here?

 No communication network available which creates communication gap between the health centre and the main hospital.  There is lack of transport to facilitate health workers movement during outreach programs and implementation of health programs.  Health programmes on radio, posters and brochures are only in Karamojong language creating an information gap for Ik people. 3. Recommendations What do you think needs to be done to improve health sector facilities / services here?

 Number of staff to be increased from 3 to 9.  Staff housing to be constructed so as to motivate them to offer quality services.  General structure of the health centre to be improved. 3.1. What are your recommendations on health?  Health equipment supply to be increased due to wide catchment area.  Power to be installed for instance solar or standby generator for the purpose of proper storage of medicine and lighting as well.  Ambulance and bicycles to be given to VHTs.  Hiring Ik staff in the health department to make them help each other well.

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Meeting Record

Week Meeting date 4 April 2016 Recorded by Richard Meeting with Obongi HC IV Administrators on RPF, Meeting/subject IPP and IPF For Uganda Reproductive, Maternal, Total pages 2 Neonatal, and Child Health Improvement Project

Item Update

1. Introduction The team leader started explained the proposed project and purpose of the consultation exercise and how findings

would be utilised in preparation of the project‟s ESMF. 2. Issues discussed How is the land owned?

Land on which Obongi HC IV is located by was donated by the local community which currently has increasing land scarcity. Although there is congestion within the health centre fence, the community does not welcome the idea of

donating any more land to the healthcare facility. There was noted a need to acquire a larger land parcel which can accommodate all the health facility space needs, and a new site had already been identified and meeting held with the family of the landowner which agreed to offer 88.8 acres of land. There was reported a plan to have a hospital in the future and a nurse training school. How has the affected health centre managed this problem?

“We, tried by all means to come to a common agreement with them but it failed therefore the issue is still in court waiting for the court ruling”. How do you want the District Land Board to help?

They should ensure that all government facilities have documented ownership in form of a title deed in order to avoid occurrence of similar problem in the future. 2.1. How are sub-county authorities involved in managing land ownership issues between health center and communities?

They have helped by requesting that all government entities have their land surveyed, registered and title deeds issued to avoid encroachment. Are there strong existing laws to protect land owned by the healthcare facilities?

Yes there are land ordinances enacted by the district land office.

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Item Update

What needs does this health centre have?

 An x-ray machine.  There is need to have personnel to operate an ultrasound machine which currently lacks an operator.  We should have two doctors to make it easier to run both administrative work and health issues.  An ambulance.  Water system needs to be repaired: the current water has a lot of iron which stains equipment.  Solar lighting systems are always affected during rainy season.  The proximity of the isolation ward (TB), to the boardroom and out patients department is a challenge to healthcare providers. Therefore we request that it is shifted elsewhere.  There is lack of shade for OPD that is screening of patients is done under a mango tree so we are with the view of having a permanent shade. There should be a shaded connecting walkway to the ward to for protection from rain and very hot sunshine.  We also need to acquire a mortuary for the health centre to help bury dead ones decently.  For proper waste management, an incinerator to is required because at the moment an open rubbish pit is used for disposal of medical waste- this is a huge public health risk.  The drug store is too congested and not in good condition for storing drugs: on hot days temperature in there rises up to 40oC.  Finally internet service to be installed in order to ease communication within and outside the health centre

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Week Meeting date 4 April 2016 Recorded by Richard Meeting with Obongi Health Centre IV Medical Staff on RPF, IPP and IPF For Uganda Reproductive, Meeting/subject Total pages 1 Maternal, Neonatal, and Child Health Improvement Project

Item Update

3. Introduction The team leader started explained the proposed project and purpose of the consultation exercise and how findings

would be utilised in preparation of the project‟s ESMF. 4. Issues discussed What are the most common diseases you register in Obongi health centre? Malaria, pneumonia, trauma, gastro-intestinal disorder, intestinal worms and diarrhoea What is the most rare but dangerous disease encountered at the health center ? Sleeping sickness. Are there staff in the health facility who speak the language of Obongi people? Yes, there is completely no language barrier. Are you aware of any cultural practices preventing people from visiting health centres for treatment? Yes, the traditional healers, herbalists, and the witchdoctors.

Are there any harmful cultural practices which affect health? Not any today but in the past there was a cultural practice of cutting marks on babies chests in a decorative pattern How do you manage medical waste? We use a rubbish pit for open air burning of solid medical waste. 4.1. Are there any needs concerning waste management? Yes, there is need to have an incinerator and placenta pit for proper disposal of medical waste. Is construction waste managed well? This waste is somehow managed well but not satisfactorily. Do you have a health centre cemetery? No we do not have a cemetery. Not even the health centre mortuary. Why don’t you have a mortuary? For so long we have complained for it but there is no fund for the construction Do you have land which can be allocated for cemetery? No, it has to be purchased What can be done to acquire land for a mortuary ? There are two options: either the health center buys land for this purpose or it requests the local community to donate land, however it is unlikely that this would be successful without it (community) asking for compensation or land purchase at market value

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Week Meeting date 4 April 2016 Recorded by Richard Meeting with Village Health Teams VHTs on RPF, Meeting/subject IPP and IPF For Uganda Reproductive, Maternal, Total pages 2 Neonatal, and Child Health Improvement Project

Item Update

5. Introduction The team leader started explained the proposed project and purpose of the consultation exercise and how findings

would be utilised in preparation of the project‟s ESMF. 6. Answer session Are village heath teams active and functioning effectively?

Yes we are active. How do you solve health issues in your villages?

 We start by identification and counselling affected persons.  We administer first aid and pain killers to them.  Then we prepare them for referral to a healthcare facility.  We strive to involve local leaders in health matters such as proper sanitation.  We advise community on disadvantages of poor health practices When you come to the health centre do you get proper services supposed to be provided by a Health Centre IV facility?

 There are always challenges: staff are not enough.  Blood transfusion services are lacking and cases of children with anaemia dying on a weekly basis are not rare.  Fuelling of the health centre ambulance at a fee of 80,000 per trip remains a big financial constraint. This is because the health centre provides the vehicle and the driver only but the fuel cost should be borne by patients. It is not easy for a poor peasant to quickly mobilise UgShs 80,000 at short notice moreover 6.1. during an emergency.  There is a major problem in the operation theatre since there is only one doctor to handle both minor and major operations.  Moyo General Hospital is the closet referral hospital is located a very long distance away and that is why sometimes patients go to Adjumani District.  There is inadequate water supply at Obongi Health Centre IV. And the water has a high iron content which stains medical equipment and tools.  There is a problem of diagnosis in the health centre, there when you come with a complain of headache you will be given malaria treatment even before proper investigations done. Is it a challenge to bring patients from villages to the health centre?

It is not challenging to nearby villages but serious for people in distant locations far because bicycle ambulances which were given are either all broken down or considered outdated, Motorcycles are easier to use nowadays. What are your suggestions?

Bicycls ambulance to be given and put under the control of the VHTs to manage them but kept by the village local council chiefs (LCs).

People fear using bicycles because they take long to reach the health centre in an emergency. People prefer to use motor-cycles instead and if possible, motorcycle ambulance should be provided.

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Item Update

In your view, how do you want your health centre to be like?

 At least we hope to have two doctors to manage the high number of patients.  The theatre should be improved and even an ultra sound department opened up.  More specialized staffs should be hired for instance Dental health, Eye Care, ENT clinic.  Power system that is the generator should be properly maintained in order to avoid power blackouts, and its fuel should always be available in adequate quantities.  Admission rooms should be enlarged and separated accordingly. This is because at the moment there is only one ward called the general ward handling all illnesses apart from maternity, regardless of age and sex.  Isolations wards to be erected to avoid transmission of air borne diseases As VHTs do you know of any cultural practices preventing people to seek services from health centers?

There might be there but not very common due to rising literacy levels and sensitization done by VHTs. Do you have staff here in the hospital that speaks local languages? Yes. Are there any language barriers in your health centre?

It is not a problem because here we have three languages namely Gimara, Madi and Lugbara which we are all comfortable with. What is the most rare disease but dangerous here?

Cholera and Meningitis. What are the challenges faced by the VHTs?

 There is low motivation in terms of salary and wages.  Health kits given to us are not stocked/supplied with medicines in time.  There is no followup after training us on health issues.  Mobilization gadgets like micro-phones, public address systems and loud speakers are not availed to us making mobilization a problem.  We lack training and refresher courses to keep abreast with on health issues.  Lack of gear like gumboots, torches, overalls, gloves to avoid riskof contracting diseases from patients.

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Week Meeting date 31 March 2016 Recorded by Richard Meeting with Kaabong District Health Officials and Kamion HC II Officials on RPF, IPP and IPF For Meeting/subject Total pages 2 Uganda Reproductive, Maternal, Neonatal, and Child Health Improvement Project

Item Update

4. Introduction The team leader started by introducing himself, the project and purpose of the meeting which was primarily to inquire abotu health related issues concerning the Ik people in Kaabong district.

Kamion Health Centre II is one of the health centre located in the Ik community.

The DHO welcomed the team and he expressed gratitude to consult the Ik people who for long have been marginalized and seen as minority among the people of the district.

5. Issues discussed Do you have Village Health Team (VHT) in Kaabong District? We have them in all the sub-counties and villages. Are they active in their work? Yes they are active. What common diseases are there among the IK? There are many diseases but the most common ones are, Malaria, Respiratory Tract Infections (RTIs), Diarrhoea, Gastro-interties, eye infections and skin diseases.

Which is the most prevalent but most dangerous? Malaria, Chicken pox, dysentery Are there staff who speak Ik language in health center(s) visited by Ik people? Unfortunately no and Ik people are compelled to use Karamojong language since they are the minority. Do the IK people practice any traditional health practice? Yes for example consulting traditional healers, medicine men/women and foretellers. Do Ik people have culture practices that may be harmful to their health? They copy the practice of the Karamojong for example body tattooing. Are the services provided to the IK very specific or general even to the other communities? No special services are provided to the Ik people. However, services such as safe delivery education are often 5.1. offered, and they (Ik) are also taken as priority at any time, for example they are always attended to 24 hours 7 days a week. Is there any cultural practice that prevents them from seeking medical help? Not many apart from the practice of mothers demanding to keep placentas after birth. What is the staffing of health centre II? It is supposed to be 9 staff; however for our case we have only 3. Do you offer services of Health Centre II or Health Centre III? This is Health CenterII which is meant to offer only out-patient department (OPD). However being the only health centre in the area we offer also other services for health centre III for example, antenatal care (ANC), family planning and deliveries and in-patient (Admission) but with only one bed. Does the community get epidemics and when? We get epidemics especially during wet season when there are many mosquitoes. How does Kamion HC II manage medical waste? Through segregation into different categories since there are different types of waste for example pharmaceutical waste, human excretes, and other waste. Do you have proper waste disposal facilities? No, due to the fact that there is no functional incinerator. How does the HC dispose of unclaimed dead bodies? They are always taken to the hospital cemetery

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Item Update

 No communication network available which creates communication gap between the health centre and the main hospital.  There is lack of transport to facilitate health workers movement during outreach programs and implementation of health programs.  Health programmes on radio, posters and brochures are only in Karamojong language creating an information gap for Ik people. 6. Recommendations What do you think needs to be done to improve health sector facilities / services here?

 Number of staff to be increased from 3 to 9.  Staff housing to be constructed so as to motivate them to offer quality services.  General structure of the health centre to be improved. 6.1. What are your recommendations on health?  Health equipment supply to be increased due to wide catchment area.  Power to be installed for instance solar or standby generator for the purpose of proper storage of medicine and lighting as well.  Ambulance and bicycles to be given to VHTs.  Hiring Ik staff in the health department to make them help each other well.

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Week Meeting date 31 March 2016 Recorded by Richard Meeting with Kamion HC II VHTs on RPF, IPP and Meeting/subject IPF For Uganda Reproductive, Maternal, Neonatal, Total pages 1 and Child Health Improvement Project

Item Update

7. Introduction The team leader started by introducing himself, the project and purpose of consultations that would benefit stakeholders and the project.

8. Answer session When visit a local health center do you get all the services you expect? No, not all, there are some problems not handled by the health center. What are other problems faced?  security since the area is a route for the cattle raiders.  Network to communicate health related issues to the unit.  Inadequate number of qualified staffs to handle patients.  Problem of common but very important medicines such as panadol. If there is health problem how do you handle it as a VHT? We help the sick with first aid then later take them to the health unit for further investigation and treatment. 8.1. How do you think this health centre should be help to improve?  Clean/safe drinking water to be provided.  Need to construct more structures to accommodate the ever rising health related issue.  The VHT should be supported with means of transport.  The standard to be upgraded to HCIII.  Need to fence it to avoid encroachers and to accommodate patients in quiet environment. What other cultural practices prevent people to seek health assistance? Preventing children to go for immunization and the language use in the health centre which does not favour the Ik patients.

Week Meeting date 1 April 2016 Recorded by Richard Meeting with the Ik Local Community on RPF, IPP Meeting/subject and IPF For Uganda Reproductive, Maternal, Total pages 1 Neonatal, and Child Health Improvement Project

Item Update

1. Introduction The Ik communities were mobilized by the area LCI for a meeting with the team in one of the village and the

following were their responses to the questions asked. 2. Answer session

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Item Update

Do you people have communication challenges when you visit a local health centre?

There was mixed answers: some people said yes because they did not speak know Karamojong language well yet those at the health facility speak only that language, while others said no problem because they spoke Karamojong. Do you think it would be good if one of you was trained to work in the local health centre?

Yes it would be a very good idea 2.1. Why? Because he/she would avoid the communication barrier and secondly it will help to reduced marginalization of the Ik people. What are the common diseases you suffer from? Malaria, headache, skin diseases, scabies, eye infections. What challenges do you face from the health centre?

 There is no adequate drug to cater for us and the neighboring communities.  There are few healthcare staff making the ratio of patient to staff high.  The distance from peoples homes to the hospital is too long.

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Week Meeting date 13 April 2016

Recorded by Richard

Meeting with Serere Health Centre IV VHTs on RPF, IPP and IPF For Uganda Reproductive, Meeting/subject Total pages 1 Maternal, Neonatal, and Child Health Improvement Project

Item Update

Introduction 1.

The team leader introduced purpose of the meeting and importance of stakeholder consultation process to the project as well as meeting World Bank (lender) and Uganda Government requirements .

Answer session 2.

Common diseases registered in Serere Health Centre IV

Malaria affects everybody across all ages. Diarrhoea is mainly in children so are Gastroenteritis, RTIs, Pneumonia.

Rare but dangerous?

TB, Cancer, Heart disease, intestinal obstructions, uterine rupture.

Cultural practices preventing people from seeking medical attention

 Mainly in Teso region, women are not supposed to show their pregnancy until you can‟t avoid it. 2.1. That makes women go for antenatal late, within the third trimester.

 There was a religious sect that had started in the area and was against Male circumcision but with the help of VHTs sensitization it was eliminated in the area. Are the VHTs active?

VHTs are very active,

 Acts as a leak between the Health facility and the community;  Refer the sick to the Health facility;  Clients mobilization, Family planning, immunization and HIV outreaches

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Item Update

waste management

Generally waste management is very poor;

 They use open burning is used to treat and dispose most waste generated;  Placenta pit is located very close to Maternity ward and the Trading Centre;  The health facility has no incinerator; the only one constructed had design flaws and was never used. Lands HC land has been encroached on and the issue was put to the attention of Health monitoring team. Therefore, HC land should be surveyed, titled and fenced off to avoid future land encroachers Challenges at the Health facility

 Current staffing is still below the level of a Health centre IV;  The Health centre structures are very old especially the Maternity ward;  The CH lacks IPD wards; both male and female share the ward and female ward is very congested , old and too small; Isolation ward and surgical ward, and as a result TB patients are treated as out-patients;  The HC lacks lighting facilities; the solar equipment is faulty so as back up health workers use small lanterns or flash light for lighting;  The operating theatre was renovated recently but the equipment are very old some are outdated and others lack simple spares;  The mortuary building at the facility is too small and does not have any equipment to hold bodies for long;  Most of the equipment was acquired from development partners through projects, when projects end maintenance and repair becoming a problem due to lack of funds.

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The general ward built in 1939 for both male and female patients

Female patients‟ ward with faulty solar system

An derelict incinerator that was never used due to poor design

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Week Meeting date 13 April 2016

Recorded by Richard

Meeting with Serere Health Centre IV VHTs on RPF, IPP and IPF Meeting/subject For Uganda Reproductive, Maternal, Neonatal, and Child Health Total pages 1 Improvement Project

Item Update

3. Introduction The team leader the project, explained purpose of the consultation meeting and opened a question and

answer session.

4. Answer session Common diseases handled by VHTs attached to Serere Health Centre IV Malaria, Measles, Diarrhoea, Cough. Rare but dangerous? Hepatitis B and TB Cultural practices preventing people from seeking medical attention  Mainly in Teso region, women are not supposed to show their pregnancy until you can‟t avoid it. That makes women go for antenatal late within the third trimester.  Children with measles are not given certain foods like eggs, meat, will not bathe and kept indoors. 4.1. Challenges  Poor motivation and facilitation since we are the Health centre I;  Lack PPE such as gum boots, groves and rain coats  At risk of contracting Hepatitis B and TB;  Lack transport;  Lack data tools, register, referral forms and report forms  The VHT to Household ratio is 1: 250; higher than 1: 25 households intended Grievance Mechanism VHTs meet monthly to share information and solve prevailing challenges and for these meetings we usually invite concerned parties to be present and sometimes the health centre In-Charge and religious leaders.

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Consultation record with Batwa indigenous people Week Meeting date April 2016 Recorded by Richard Meeting/subject Meeting with Batwa community members Total pages 1 Item Consultation

1. Introduction The team consulted Batwa community at Kitariro CH II premises, Kanungu District in a meeting organized with assistance of one Nibarema Godfrey. He introduced the consultants team to the congregation and encouraged his kinship to freely air out their views about the project‟s possible impact and benefits.

2. Issues discussed Diseases the Batwa community noted as prevalent are: Malaria, diarrhoea, cough, ulcers, allergy and HIV.

Language used for communication at health centers: Language of communication at the nearest HC is Rukiga and Batwa people, who speak it fluently, said were comfortable with it. Traditional practices that prevent Batwa from seeking health services

Cut marks on children‟s chests to prevent and treat pneumonia. 2.1. Challenges  Patients referred by VHTs and HCs for further management do not have transport to their destinations, they are usually carried on locally made stretchers for long distances;  Lack of In-Patient Department (IPD), especially maternity ward for women to deliver;  Lack of dental services, as a result some Batwa people use crude implements including pliers to extract teeth;  Lack of electricity and lighting in HCs. 3. Recommendations  Provision of ambulances (vehicles or motorcycles);  Upgrade one of the nearby HC IIs to a level to offer IPD services, especially maternity ward; 3.1.  Provide dental service equipment and personnel; and  Provide solar power equipment to the health center

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Week Meeting date April 2016 Recorded by Richard Meeting/subject Meeting with the In-charge of Kitariro HC II Total pages 1 Item Consultation

1. Introduction The team met the officer at her office, Kitariro CH II in Kanungu District. Kitariro is one the health facilities accessed by the Batwa in Kanungu.

2. Issues discussed Common diseases among the Batwa people:

The officer mentioned malaria, gastro-intestinal disorders, ulcers and respiratory tract infections as the common diseases. Coccidiosis (Butamba) was named as a rare but dangerous disease, especially among population near Bwindi Forest. As result, people near the forest receive vaccines twice every year as a cautionary measure. In addition, scabies was reported as a seasonal disease especially during dry seasons. Common language healthcare staff use to communicate with Batwa people

The widely used language is Rukiga. This is because the minority Batwa have learned to speak the language of the majority- Rukiga. Secondly, the Batwa are uneducated and therefore cannot get technical placement at the HC, which up to now has precluded opportunity for a native Batwa person being a staff at the health center. 2.1. Traditional practices that prevent Batwa from seeking health services

The Batwa believe that traditional healers cure/prevent witchcraft, false teeth and pneumonia, therefore they consult them first and only visit a health center when the healers fail to provide healing solutions. Healthcare waste management: Waste generated is sorted and disposed of by opening burning in pits. It was also noted that the HC does not have mortuary facilities. Land resource: Church of Uganda through Kinkiizi Dioceses brought land for the Batwa to settle on. The In- Charge of the health center indicated that the HC has sufficient development and for expansion. Challenges: Patients referred by VHTs and HCs for further treatment or management always lack transport, resorting to usually being carried on locally made stretchers for as long as 30 km before they get a taxi to a hospital. 3. Recommendations Health services: Provision of ambulances (vehicles or motorcycles) is essential for this community 3.1. Waste management: For proper waste management, a suitable incinerator should be constructed

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Week Meeting date April 2016 Recorded by Richard Meeting/subject Meeting with the VHTs Total pages 1 Item Consultation

1. Introduction The team met VHT members at Kitariro CH II premises, Kanungu District.

2. Issues discussed Challenges cited  Lack incentives hence motivation for their services;  Lack of adequate safety wear such as gumboots and umbrellas and tools (registers and first aid boxes) needed for duties. VHT members indicated receiving few medical supplies which also take long to get 2.1. replenished once used up;  Members indicated lack of relevant information/ health care knowledge and required continual training.  Batwa community‟s mindset was also cited as challenge: Batwa people are used to free things and are reluctant to pay for any service however little the charge might be 3. Recommendations Health services

 Monetary allowances should be provided; 3.1.  Government should increase quantity and frequency of replenishment of health supplies;  VHT should be provided with adequate safety gear and tools; and  Community should be sensitized to change their mindset of always expecting free services

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Week Meeting date April 2016 Recorded by Richard Meeting/subject Focus Group Discussion with Batwa Women Total pages 1 Item Consultation

1. Introduction The team met a group of Batwa women at the Kitariro HC II premises, Kanungu District.

2. Issues discussed Diseases among the Batwa community

The Batwa women mentioned some of the common diseases in their children and these included; Malaria, Diarrhea, Pneumonia, Cough and flue Health services for women Family planning Challenges 2.1.  Lack of maternal ward, therefore expecting mothers have to travel long distances to Bwindi Hospital to deliver;  Women cited lack of access to sanitary facilities;  Mothers and children lack transport to the HCs;  Batwa women who are financially disadvantaged wait in queues at the HCs for long periods which sometimes leads of loss of lives of mothers, babies or both.

3. Recommendations

 Upgrade a HC II in their community to offer IPD services, including maternal care; 3.1.  Recruit professional midwives to help women to deliver;  Provide motorcycle ambulances to take pregnant women to the HCs;

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Week Meeting date April 2016 Recorded by Richard Meeting/subject Meeting with the Secretary of Kinkizi Diocese Total pages 1 Item Consultation

1. Introduction The team met the officer in his office at Kinkizi Diocese.

2. Issues discussed Contribution of Church to Batwa well-being

 The church of Uganda through Kinkiizi Diocese brought land and settled Batwa people. 2.1.  The church established “Batwa Development Program” to give assistance to Batwa in education, knowledge for agriculture and health services.  It was also mentioned that Batwa people pay UgShs2000 per year quarter for treatment at health centers (many of whom consider it high and not affordable).

Week Meeting date April 2016 Recorded by Richard Meeting with the Coordinator of Health Sector on Meeting/subject IPPF for Uganda Reproductive, Maternal, Neonatal, Total pages 1 and Child Health Improvement Project Item Consultation

1. Introduction The team met the officer in his office, Kanungu District.

2. Issues discussed Health Services

The Batwa community have a number of health facilities they can visit to access health services, such as:

. BWINDI HOSPITAL . KIHEMBE HEALTH CENTER II . KITARIRO HEALTH CENTER II . JUMBA SATELLITE CLINIC . KANYASHOJE HEALTH CENTER II Diseases among the Batwa community

The officer mentioned Malaria, Malnutrition, scabies, cough and diarrhoea as most common diseases amongst the Batwa.

Coccidiosis (Butamba) was named as a rare but dangerous disease, especially among population near Bwindi Forest. As result, populations near the forest receive vaccines twice every year as a preventative measure.

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Challenges Batwa people commonly face

 Lack of maternal ward;  The shs.2000/= paid quarterly for treatment is still high for Batwa;  Batwa people are harsh to be handled and they have a negative attitude towards healthcare staff;  The Batwa always expect receiving free services;  The Batwa travel long distances to Bwindi Hospital where they receive free treatment.

. Language of communication

The District Health Officer informed that the Batwa people use Rukiga Language for communication. Therefore there is good communication between the Batwa and other people they surround.

Traditional practices that prevent Batwa from seeking health services

He said that the Batwa people have some cultural practices that prevent them from seeking health medication. It was revealed for instance that Batwa people believe false teeth are important and they do not seek medical attention to remove them from babies. Recommendations

 HCs need more clinical officers in the Batwa community;  The project interventions should include providing Infrastructure such as maternal wards and laboratories for better services for the Batwas;

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Photographs of stakeholder consultations

Consultation meeting with In charge Obongi Health Centre IV

Focus group discussion of IK Women

Consultation meeting with Health Inspector, Chairperson Health Management Committee and Senior Nursing Officer Obongi Health Center IV.

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Consultation meeting with VHTs at Obongi Health center IV

Small lamps used at in a maternity ward at night .

An IK homestead

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Security fence around an Ik homestead for protection from hostile tribes like the Karamojong and Turkana.

A consultation meeting with IK community Village Health Team at Kamion Health Centre II.

A refrigerator at Kamion Health Centre II IK community

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A typical dwelling in an Ik household

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Annex 6: ESMP template Introduction

This ESMP includes several matrix of E&S mitigation measures throughout the project lifecycle. A full-fledged ESMP shall include other key elements such as institutional arrangement, capacity building and training plan, and background information. The Borrower may incorporate pertaining sections in the ESMF into this ESMP, with necessary updates.

The matrix stress lifecycle management of environmental and social (E&S) risks, including planning and design, construction, operational and decommissioning stages. Because COVID-19 is a latest threat to global public health, preparedness and responses vary across countries. Nonetheless, avoiding and minimizing chances of infection and protecting public health sit at the core. Properly managing E&S risks associated with COVID-19 responses serves the purpose. Thus professional efforts should be made throughout the project lifecycle. The issues and risks presented in the matrix are based on studies of COVID-19 responses thus far, issues of similar Bank financed healthcare sector projects. They should be expanded and/or updated during the project environmental and social assessment process, including stakeholder engagement.

Many pertaining mitigation measures and good practices are well documented in WBG EHS Guidelines, WHO guidelines and other GIIPs. They should be followed in general, taken into account country context. Proper stakeholder engagement including close involvement of medical and healthcare waste management professional should be conducted in determining the mitigation measures.

The Infection Control and Waste Management Plan is considered part of this ESMP. The ESMP should make reference to pertaining E&S instruments as required by ESF, including LMP and RAP.

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Table 1 Environmental and Social Risks and Mitigation Measures during Planning and Designing Stage

Key Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget Identify the type, location and scale of healthcare facilities (HCF) Identify the needs for new construction, expansion, upgrading and/or rehabilitation Identify the needs for ancillary works and associated facilities, such as access roads, construction materials, supplies of water and power, sewage system. Identify the needs for acquisition of land and assets (incl. acquiring existing assets such as hostel, stadium to hold potential patients) Identify onsite and offsite waste management facilities, and waste transportation routes and service providers Identify needs for transboundary movement of samples, specimen, reagent, and other hazardous materials. Identify needs for workforce and type of Develop LMP project workers Identify the needs for using security personnel during construction and/or operation of HCF HCF design – general . Structural safety risk; . Functional layout and engineering control for nosocomial infection

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Key Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget HCF design - considerations for differentiated treatment for groups of higher sensitivity or vulnerable (potentially the elderly, those with preexisting conditions, or the very young) HCF design - considerations for those with disabilities, taking into consideration the principle of universal access as and when appropriate; Estimates of healthcare waste (HCW) streams in the HCF

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Table 2 Environmental and Social Risks and Mitigation Measures during Construction Stage

Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

Clearing of vegetation and trees; Impacts on natural habitats, Construction activities near ecological resources and ecologically sensitive areas/spots biodiversity General construction activities . Impacts on soils and Foundation excavation; borehole groundwater; digging . Geological risks;

General construction activities - . Resource efficiency issues, including raw materials, water and energy use; . Materials supply General construction activities – . Construction solid waste; general pollution management . Construction wastewater; . Nosie; . Vibration; . Dust; . Air emissions from construction equipment General construction activities – . Fuel, oils, lubricant hazardous waste management General construction activities – . Labor issues . Labor issues . Refer to LMP General construction activities – Occupational Health and Safety (OHS) General construction activities- traffic and road safety General construction activities – security personnel General construction activities – . Acquisition of land and

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Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget land and asset assets General construction activities - . Labor influx Labor . Worker‟s camp General construction activities - . GBV/SEA issues General construction activities – . Cultural heritage Chance-finds procedure cultural heritage General construction activities – emergency preparedness and response Construction activities related to onsite waste management facilities, including temporary storage, incinerator, sewerage system and waste water treatment works Construction activities related to demolition of existing structures or facilities (if needed) To be expanded

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Table 3 Environmental and Social Risks and Mitigation Measures during Operational Stage

Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

General HCF operation – . General wastes, Environment wastewater and air emissions General HCF operation – OHS . Physical hazards issues . Electrical and explosive hazards . Fire . Chemical use . Ergonomic hazard . Radioactive hazard HCF operation – Labor issue . HCF operation - considerations for . differentiated treatment for groups of higher sensitivity or vulnerable (potentially the elderly, those with preexisting conditions, or the very young) HCF operation - considerations for . those with disabilities, taking into consideration the principle of universal access as and when appropriate; HCF operation - Infection control . and waste management plan Waste minimization, . reuse and recycling Delivery and storage of . specimen, samples, reagents, pharmaceuticals and medical supplies Storage and handling of . specimen, samples,

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Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

reagents, and infectious materials Waste segregation, . . packaging, color coding and labeling Onsite collection and . . transport Waste storage . Onsite waste treatment and disposal Waste transportation to and disposal in offsite treatment and disposal facilities Transportation and disposal at offsite waste management facilities HCF operation – transboundary movement of specimen, samples, reagents, medical equipment, and infection materials Operation of acquired assets for holding potential COVID-19 patients Emergency events . Spillage, . Emergency Response Plan . Occupational exposure to infectious . Exposure to radiation, Accidental releases of infectious or hazardous substances to the environment, . Medical equipment failure, . Failure of solid waste

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Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

and wastewater treatment facilities, -fire . -Other emergent events To be expanded

Table 4 Environmental and Social Risks and Mitigation Measures during Decommissioning

Key Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

Decommissioning of interim HCF Decommissioning of medical equipment Regular decommissioning To be expanded

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Annex 7: Infection Control and Waste Management Plan (ICWMP) Template

1. Introduction 1.1 Describe the project context and components; 1.2 Describe the targeted healthcare facility (HCF): . Type: E.g. general hospital, clinics, inpatient/outpatient facility, medical laboratory; . Special type of HCF in response to COVID-19: E.g. existing assets may be acquired to hold yet-to-confirm cases for medical observation or isolation; . Functions and requirement for the level infection control, e.g. biosafety levels; . Location and associated facilities, including access, water supply, power supply; . Capacity: beds 1.3 Describe the design requirements of the HCF, which may include specifications for general design and safety, separation of wards, heating, ventilation and air conditioning (HVAC), autoclave, and waste management facilities.

2. Infection Control and Waste Management

2.1 Overview of infection control and waste management in the HCF . Type, source and volume of healthcare waste (HCW) generated in the HCF, including solid, liquid and air emissions (if significant); . Classify and quantify the HCW (infectious waste, pathological waste, sharps, liquid and non-hazardous) following WGB EHS Guidelines for Healthcare Facilities and pertaining GIIP. . Given the infectious nature of the novel coronavirus, some wastes that are traditionally classified as non- hazardous may be considered hazardous. It’s likely the volume of waste will increase considerably given the number of admitted patients during COVID-19 outbreak. Special attention should be given to the identification, classification and quantification of the healthcare wastes. . Describe the healthcare waste management system in the HCF, including material delivery, waste generation, handling, disinfection and sterilization, collection, storage, transport, and disposal and treatment works; . Provide a flow chart of waste streams in the HCF if available; . Describe applicable performance levels and/or standards; . Describe institutional arrangement, roles and responsibilities in the HCF for infection control and waste management. 2.2 Management Measures . Waste minimization, reuse and recycling: HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety consideration. . Delivery and storage of specimen, samples, reagents, pharmaceuticals and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of the hazardous medical goods.

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. Waste segregation, packaging, color coding and labeling: HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. . Onsite collection and transport: HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. . Waste storage: A HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF‟s storage area for disposal within 24 hours. . Onsite waste treatment and disposal (e.g. an incinerator): Many HCFs have their own waste incineration facilities installed onsite. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator‟s capacity. In case any gaps are discovered, corrective measures should be recommended. For new HCF financed by the project, waste disposal facilities should be integrated into the overall design and ESIA developed. Good design, operational practices and internationally adopted emission standards for healthcare waste incinerator can be found in pertaining EHS Guidelines and GIIP. . Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well- performed incinerator onsite. Not all healthcare wastes are suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by local government or private sector are probably needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator‟s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. . Wastewater treatment: HCF wastewater is related to the hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into municipal sewer sewerage system, the HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the municipal wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where municipal sewage system is not in place, HCF should build and proper operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There‟re also cases HCF wastewater is transported by trucks to a municipal wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted.

3. Emergency Preparedness and Response Emergency incidents occurred in an HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, and fire. These emergency events are likely to seriously affect medical workers, community, HCF‟s operation and the environment.

Thus, an Emergency Response Plan (ERP) that is commensurate with the risk levels is recommended to be developed. The key elements of an ERP are defined in ESS 4 Community Health and Safety (para. 21).

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4. Institutional Arrangement and Capacity Building A clearly defined institutional arrangement, roles and responsibilities should be included. A training plan with recurring training programs should be developed. The following aspects are recommended: . Define roles and responsibilities along each link of the chain along the cradle-to-crave infection control and waste management process; . Ensure adequate and qualified staff are in place, including those in charge of infection control and biosafety and waste management facility operation. . Stress the chief of an HCF takes overall responsibility for infection control and waste management; . Involve all relevant departments in a healthcare facility, and build an intra-departmental team to manage, coordinate and regularly review the issues and performance; . Establish an information management system to track and record the waste streams in HCF; and . Capacity building and training should involve medical workers, waste management workers and cleaners. Third-party waste management service providers should be provided with relevant training as well. . 5. Monitoring and Reporting Many HCFs in developing countries face the challenge of inadequate monitoring and records of healthcare waste streams. HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. HCF is encouraged to develop an IT based information management system should their technical and financial capacity allow.

As discussed above, the HCF chief takes overall responsibility, leads an intra-departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing system should be in place.

Externally, reporting should be conducted per government and World Bank requirements.

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Table ICWMP

Activities Potential E&S Issues and Risks Proposed Mitigation Measures Responsibilities Timeline Budget

General HCF operation – General wastes, wastewater and Environment air emissions General HCF operation – OHS Physical hazards issues Electrical and explosive hazards Fire Chemical use Ergonomic hazard Radioactive hazard HCF operation - Infection control . and waste management plan Waste minimization, . reuse and recycling Delivery and storage of . specimen, samples, reagents, pharmaceuticals and medical supplies Storage and handling of . . specimen, samples, reagents, and infectious materials Waste segregation, . packaging, color coding and labeling Onsite collection and transport Waste storage Onsite waste treatment and disposal Waste transportation to and disposal in offsite treatment and disposal facilities

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HCF operation – transboundary movement of specimen, samples, reagents, medical equipment, and infection materials Emergency events . Spillage, Emergency response plan . Occupational exposure to infectious . Exposure to radiation, Accidental releases of infectious or hazardous substances to the environment, . Medical equipment failure, . Failure of solid waste and wastewater treatment facilities, -fire -Other emergent events Operation of acquired assets for holding potential COVID-19 patients To be expanded

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Annex 8: Infection and Prevention Control Protocol (Adapted from the CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in Healthcare Settings)

HEALTH CARE SETTINGS

1. Minimize Chance of Exposure (to staff, other patients and visitors)  Upon arrival, make sure patients with symptoms of any respiratory infection to a separate, isolated and well- ventilated section of the health care facility to wait, and issue a facemask  During the visit, make sure all patients adhere to respiratory hygiene, cough etiquette, hand hygiene and isolation procedures. Provide oral instructions on registration and ongoing reminders with the use of simple signs with images in local languages  Provide alcohol-based hand sanitizer (60-95% alcohol), tissues and facemasks in waiting rooms and patient rooms  Isolate patients as much as possible. If separate rooms are not available, separate all patients by curtains. Only place together in the same room patients who are all definitively infected with COVID-19. No other patients can be placed in the same room.

2. Adhere to Standard Precautions  Train all staff and volunteers to undertake standard precautions - assume everyone is potentially infected and behave accordingly  Minimize contact between patients and other persons in the facility: health care professionals should be the only persons having contact with patients and this should be restricted to essential personnel only  A decision to stop isolation precautions should be made on a case-by-case basis, in conjunction with local health authorities.

3. Training of Personnel  Train all staff and volunteers in the symptoms of COVID-19, how it is spread and how to protect themselves. Train on correct use and disposal of personal protective equipment (PPE), including gloves, gowns, facemasks, eye protection and respirators (if available) and check that they understand  Train cleaning staff on most effective process for cleaning the facility: use a high-alcohol based cleaner to wipe down all surfaces; wash instruments with soap and water and then wipe down with high-alcohol based cleaner; dispose of rubbish by burning etc.

4. Manage Visitor Access and Movement  Establish procedures for managing, monitoring, and training visitors  All visitors must follow respiratory hygiene precautions while in the common areas of the facility, otherwise they should be removed  Restrict visitors from entering rooms of known or suspected cases of COVID-19 patients Alternative communications should be encouraged, for example by use of mobile phones. Exceptions only for end-of- life situation and children requiring emotional care. At these times, PPE should be used by visitors.  All visitors should be scheduled and controlled, and once inside the facility, instructed to limit their movement.  Visitors should be asked to watch out for symptoms and report signs of acute illness for at least 14 days.

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CONSTRUCTION SETTINGS IN AREAS OF CONFIRMED CASES OF COVID-19

1. Minimize Chance of Exposure  Any worker showing symptoms of respiratory illness (fever + cold or cough) and has potentially been exposed to COVID-19 should be immediately removed from the site and tested for the virus at the nearest local hospital  Close co-workers and those sharing accommodations with such a worker should also be removed from the site and tested  Project management must identify the closest hospital that has testing facilities in place, refer workers, and pay for the test if it is not free  Persons under investigation for COVID-19 should not return to work at the project site until cleared by test results. During this time, they should continue to be paid daily wages  If a worker is found to have COVID-19, wages should continue to be paid during the worker‟s convalescence (whether at home or in a hospital)  If project workers live at home, any worker with a family member who has a confirmed or suspected case of COVID-19 should be quarantined from the project site for 14 days, and continued to be paid daily wages, even if they have no symptoms.

2. Training of Staff and Precautions  Train all staff in the signs and symptoms of COVID-19, how it is spread, how to protect themselves and the need to be tested if they have symptoms. Allow Q&A and dispel any myths.  Use existing grievance procedures to encourage reporting of co-workers if they show outward symptoms, such as ongoing and severe coughing with fever, and do not voluntarily submit to testing  Supply face masks and other relevant PPE to all project workers at the entrance to the project site. Any persons with signs of respiratory illness that is not accompanied by fever should be mandated to wear a face mask  Provide handwash facilities, hand soap, alcohol-based hand sanitizer and mandate their use on entry and exit of the project site and during breaks, via the use of simple signs with images in local languages  Train all workers in respiratory hygiene, cough etiquette and hand hygiene using demonstrations and participatory methods  Train cleaning staff in effective cleaning procedures and disposal of rubbish

3. Managing Access and Spread  Should a case of COVID-19 be confirmed in a worker on the project site, visitors should be restricted from the site and worker groups should be isolated from each other as much as possible;  Extensive cleaning procedures with high-alcohol content cleaners should be undertaken in the area of the site where the worker was present, prior to any further work being undertaken in that area.

P a g e | 162 Annex 9: Format of an Environmental Report

A EIA report should include the following items (not necessarily in the order shown):

(a) Executive summary. Concisely discusses significant findings and recommended actions.

(b) Policy, legal, and administrative framework. Discusses the policy, legal, and administrative framework within which the EA is carried out.

(c) Project description. Concisely describes the proposed project and its geographic, ecological, social, and temporal context, including any offsite investments that may be required (e.g., dedicated pipelines, access roads, power plants, water supply, housing, and raw material and product storage facilities). Indicates the need for any resettlement plan or indigenous peoples development plan.

(d) Baseline data. Assesses the dimensions of the study area and describes relevant physical, biological, and socioeconomic conditions, including any changes anticipated before the project commences. Also takes into account current and proposed development activities within the project area but not directly connected to the project. Data should be relevant to decisions about project location, design, operation, or mitigatory measures. The section indicates the accuracy, reliability, and sources of the data.

(e) Environmental impacts. Predicts and assesses the project's likely positive and negative impacts, in quantitative terms to the extent possible. Identifies mitigation measures and any residual negative impacts that cannot be mitigated. Explores opportunities for environmental enhancement. Identifies and estimates the extent and quality of available data, key data gaps, and uncertainties associated with predictions, and specifies topics that do not require further attention.

(f) Analysis of alternatives. Systematically compares feasible alternatives to the proposed project site, technology, design, and operation--including the "without project" situation--in terms of their potential environmental impacts; the feasibility of mitigating these impacts; their capital and recurrent costs; their suitability under local conditions; and their institutional, training, and monitoring requirements. For each of the alternatives, quantifies the environmental impacts to the extent possible, and attaches economic values where feasible. States the basis for selecting the particular project design proposed and justifies recommended emission levels and approaches to pollution prevention and abatement.

(g) Environnemental management plan (EMP). Covers mitigation measures, monitoring, and institutional strengthening.

(h) Appendixes

(i) List of EA report preparers--individuals and organizations.

(ii) References--written materials both published and unpublished, used in study preparation.

(iii) Record of interagency and consultation meetings, including consultations for obtaining the informed views of the affected people and local nongovernmental organizations (NGOs). The record specifies any means other than consultations (e.g., surveys) that were used to obtain the views of affected groups and local NGOs.

(iv) Tables presenting the relevant data referred to or summarized in the main text.

(v) List of associated reports (e.g., resettlement plan or indigenous peoples development plan). (vi) Incidents reporting: Any serious accidents or incidents that happen during Project Implementation should be reported as per guidelines provided in “The World Bank (2018). Environment and Social Incident Response Toolkit for World Bank Staff”. This document shows reporting procedure and timelines, classification of accidents, notification procedures, and investigation (Root Cause Analysis/Development of Corrective Action Plan).

Annex 10: Healthcare Waste Management Guidelines

Simple, easy to follow guidelines for proper management of each class of waste (excerpted from the national healthcare waste management guidelines) are outlined below:

Class 1: Non-hazardous Health Care Waste i) Non-hazardous (domestic) HCW of class 1 should be placed in black bins at the point of generation. ii) All non-hazardous (domestic) HCW that is biodegradable should be disposed of in a compost pit. In places where there are municipalities, the waste should be handed over to a licensed provider or disposed of at a municipal skip. iii) Non-biodegradable waste that cannot be recycled should be landfilled. iv) Non-hazardous items that are designated for recycling should be packed in: a. Green bins marked “Non-infectious plastic” for plastics b. Black bins marked “Non-contaminated glass materials” for glass. v) Non-hazardous HCW for recycling should be taken for recycling by an approved service provider. vi) The bins for storage of HCW should be placed in all rooms, wards, and in all public areas where such waste is likely to be generated.

Class 2: Infectious Waste i) All infectious waste should be placed in yellow polyethylene bags (minimum 300 microns gauge) marked “Danger! Hazardous infectious waste” and indicated with the international biohazard symbol. ii) The bags/bin liners shall be placed in yellow bins or bag-holders. iii) Bags shall be tied or sealed with appropriate adhesive tape, removed and replaced immediately when they are no more than three-quarters full. iv) As much as possible, infectious HCW shall be incinerated in double chamber incinerators, but where appropriate, chemical treatment and autoclaving can be used as alternative methods for treating infectious waste. v) In densely populated areas, a centralized pyrolytic incinerator, reaching 8500°C and above is preferable. vi) Yellow bins for infectious waste should be located in all wards and rooms where infectious waste could be produced. Infectious waste containers should never be placed in public areas. vii) Infectious waste generated outside health facilities; for example, during SMC outreaches at schools and churches, should be handled appropriately. Put sharps in a safety box and double-bag and seal other infectious waste to ensure safety during transport to a nearby recommended disposal facility.

Class 3: Sharps i) All sharps should be placed in puncture-resistant and leak-proof cardboard or plastic safety boxes, designed so that items can be dropped in using one hand and no items can be removed. ii) The safety box should be yellow, marked “Danger!” or “Contaminated sharps.” iii) Yellow is the conventionally accepted colour and it is advisable to adhere to this convention. iv) The safety box shall be closed and sealed for disposal when it is three-quarters full. v) In particular, all disposable syringes and needles shall be discarded in the safety box immediately following injection/use. vi) The needle shall never be recapped or removed from the syringe; the whole combination shall be inserted into the safety box. vii) In very rare situations where there is need to re-cap, single hand recapping may be authorised by a senior supervisor; for example, in laboratories when intact needles on syringes are being used to transport blood samples. Two-handed recapping is an unacceptable practice under any circumstance. viii) Under no circumstances are used syringes, needles, or safety boxes to be disposed of in normal garbage or dumped randomly without prior treatment. ix) Sharps are destroyed together with infectious waste. The method of choice for destruction of full safety boxes is incineration, preferably in an appropriate double-chamber (>900°C) incinerator. x) Safety boxes must be located in all rooms and wards where injections and other sharps may be used.

Class 4: Anatomical Waste, Including Placentas i) In operating theatres, all anatomical waste, including placentas, should be collected separately and placed in red polyethylene bags of minimum 300 microns gauge, marked “Danger! Hazardous! Highly infectious waste” and indicated with the international biohazard symbol ii) The bags shall be placed in red bins or bag-holders. iii) In Uganda, the cultural preference is to have anatomical waste buried. In such situations, anatomical waste and placentas should be buried at a sufficient depth (>1m) inside the HF compound, preferably placed in a placenta pit. iv) However, when a centralized incinerator is available and culturally acceptable, the anatomical waste can be incinerated. Nevertheless, when low-cost incinerators are used, only small quantities of anatomical waste or placentas should be incinerated at any time. This is because large quantities can be difficult to incinerate and drastically reduce the performance of the system. v) Where licensed service providers are available, anatomical waste may be handed over for appropriate offsite disposal. vi) If transportation and disposal cannot be immediately ensured, anatomical waste should be stored in the mortuary. Red bins for highly infectious waste should be located in all theatres and rooms where anatomical waste, including placentas, could be produced. Highly infectious waste containers should never be placed in public areas.

Class 5: Hazardous Pharmaceutical and Cytotoxic Waste i) Hazardous pharmaceutical waste and cytotoxic waste should be sorted according to specific categories: cytotoxic drugs, narcotics; ignitable, corrosive, and/or reactive materials, as well as the waste‟s nature of formulation ii) Brown bins for pharmaceutical waste should be located in all wards and rooms where pharmaceutical and cytotoxic waste could be produced. iii) All expired pharmaceutical and cytotoxic products should be removed from shelves, labelled, and stored in a secure room or segregated area. iv) The products should be boarded off by the Board of Survey following the Public Procurement and disposal of Public Assets Act 2003 (a form should be filled in and signed by all members present as evidence). v) All sorted expired pharmaceutical and cytotoxic waste should be repacked in specific boxes such as cardboard boxes labelled “Danger! Hazardous pharmaceutical or cytotoxic waste.” vi) Clearly-labelled pharmaceutical waste from public facilities should be sent to the district medicines store that shall ensure their disposal at the central level. Non-public facilities should make prior arrangements with the National Drug Authority (NDA) to have waste disposed of. (Contact your regional NDA office for further details on assistance with the disposal of small quantities of expired pharmaceuticals). vii) Stores charged with the responsibility of storage of pharmaceutical and cytotoxic waste should follow the guidelines for storage viii) Transportation: Unlike other types of health care waste, transportation of pharmaceutical waste for final disposal should be done in the presence of NDA representatives. If the waste has narcotics, police should be notified. ix) All pharmaceutical and cytotoxic wastes should be disposed of according to recommended best practices x) Special precautions should be taken to ensure that expired and/or unusable pharmaceuticals do not pilferage (leak) back to the public.

Class 6: Highly Infectious Waste i) All highly infectious waste from HFs should be placed in red polyethylene bags of minimum 300 microns gauge marked “Danger! Hazardous highly infectious waste!” and marked with the international biohazard symbol (see Table 3). ii) Highly infectious waste (such as cholera waste) from isolation wards or permanent treatment centres should always be incinerated on-site. iii) Highly infectious waste from the medical diagnostic laboratory of the HF, such as media and culture plates, should be collected in leak-proof red polyethylene waste bags (300 microns thick) suitable for autoclaving and properly sealed. iv) Media and culture plates should be autoclaved at a temperature of 121°C at one bars for at least 20 minutes at the source (e.g., in the medical diagnostic laboratory). v) Disinfected waste should be collected and treated with infectious HCW.

vi) If a separate autoclave for waste treatment is not available at the medical diagnostic laboratory to ensure a thermal treatment, highly infectious waste should be disinfected in 10% solution of sodium hypochlorite in concentrated form and left overnight. vii) It should then be discarded in a red polyethylene bag, properly sealed and discarded with other infectious HCW. viii) If none of the above steps can be taken, highly infectious waste should at a minimum be sealed in a red polyethylene bag and directly disposed of with infectious HCW.

Class 7: Radioactive Waste i) All radioactive waste should be stored to allow decay or decomposition to diminish its radioactivity. Such waste has a minimum storage time of 10 half-life times for radioisotopes in wastes with a half-life of less than 90 days. ii) Radioactive waste should be placed in a large container or drum and labelled with the radiation symbol showing the radionuclide‟s activity on a given date, the period of storage required, and marked “Caution! Radioactive waste!” Containers or tanks with radioactive waste that has not decayed to background level should be stored in a specific marked area, with concrete walls at least 25 centimeters thick. iii) Non-infectious radioactive waste which has decayed to background level should follow the non-hazardous HCWM procedure (Class 1), while infectious radioactive waste which has decayed to background level should follow the infectious HCW procedure (Class 2). iv) Liquid radioactive waste should be discharged into the sewerage system or into a septic tank only after it has been kept in adequate tanks and allowed to decay to background level.

Class 8: Waste with High Contents of Heavy Metals i) Waste with high contents of heavy metals should normally be treated in specific recovering industries. ii) Alternatively, the waste should be encapsulated for handling and disposal. Encapsulation is a process where containers are filled three-quarters full with hazardous waste. Then material such as cement mortar, clay, bituminous sand, or plastic foam is used to fill the container. When capping material is dry, the container is buried or landfilled. iii) Wastes with high contents of mercury or cadmium should never be incinerated because of the risk of atmospheric pollution with toxic vapours.

Class 9: Effluent

Improper management, collection, treatment, and disposal of wastewater (effluent) and sludge will result in the pollution of local water sources with pathogens. This can cause numerous water- and vector-borne diseases (e.g., malaria and filariasis) by providing breeding places for the vectors, and favours the spread of parasites (e.g., roundworms or Ascaris lumbricoides). Wastewater discharged in an uncontrolled manner into the environment can lead to several waterborne diseases that are a threat to human life, such as cholera, typhoid fever, campylobacteriosis, hepatitis A and E, and schistosomiasis. By disposing of untreated wastewater in the environment, nutrients are biologically degraded in groundwater, lakes, and rivers by using oxygen present in fresh water (eutrophication). If the oxygen demand of the wastewater is too high, hypoxia (oxygen depletion) of a watercourse will result in significant environmental degradation though sucking oxygen along the path over which the water is flowing and in the process destroying lives of organisms and plants along the way. Additionally, the nutrients can increase algal production and algal blooms that will favour potentially hazardous bacteria (e.g. cyanobacteria) and might result in hazardous toxins forming that can cause illnesses, such as from exposure to cyanotoxins. Nitrate in the groundwater from untreated wastewater can result in methaemoglobinaemia, particularly in babies.

. All infectious effluents should be discharged into the sewerage system or soak pits only after being treated according to WHO standards . . Wastewater from HFs should not be released into the environment without treatment because it may contain various potentially hazardous components such as microbiological pathogens, hazardous chemicals, pharmaceutical waste, and radioactive isotopes. . Although proper treatment of wastewater from HFs is very expensive and cannot be currently foreseen in every HF in Uganda, steps 1 and 2 should be applied in order to contribute to the reduction of public health risk associated with liquid waste and wastewater.

Annex 11: Health Care Waste Management Plan Checklist

Key elements in a Health Care Waste Plan a. Clearly identifies the types of wastes that need special management (at minium following the WHO criteria and include a special focus on sharps management). b. Structures a waste management system which provides for a specific segregation system, minimizing hazardous chemical wastes, and providing safe collection of all wastes. c. Establishes clear protocols for safe and secure collection, treatment and disposal of sharps (e.g., needles, syringes, blades, and other instruments capable of inflicting a wound or a puncture). Identifies as part of the protocol the specific legal and regulatory requirements that must be followed from “cradle to grave” management of the health care wastes. This enables employees to be aware of the specific laws and regulations that they are required to comply with, as well as to be alerted to any regulatory changes that, in turn, require them to change their practices. d. Identifies specific strategies, including purchasing of supplies and equipment which minimize volume and toxicity of wastes (e.g., investment in non-mercury diagnostic technology; water-less/chemical-less x-ray processing; needless IV systems) e. Provides for an effective and defined worker safety program for all levels of staff. This would include training, provision of appropriate personal protective equipment, clear safety policies, and a 100% staff participation program for immunizations for at minimum Tetanus and Hep B. f. Provide leakproof, color coded, labeled containers for each waste stream, and puncture resistant containers for collection of sharps wherever they are generated. g. Ensure secure transportation of waste through the facility, secure storage on site while awaiting pick-up, and safe and secure transportation to treatment and final disposal. h. Identify key personnel who have charge of the total waste system (planning, documentation, evaluation, maintenance). i. Identify environmentally sound and cost- effective treatment technologies to render special waste streams harmless – this could be on-site, or off-site methods – in all cases there will be more than one technology necessary to adequately treat all wastes (e.g., silver recovery unit for radiology, xylene recover still for the lab, formaldehyde filtration for pathology, autoclave for most infectious wastes, burial/cremation contract or capacity with local facilities for body parts). j. Contracts with certified hazardous waste management firm for any chemical hazardous wastes which are not treatable by safe practices on site. k. Agreement with municipal or private landfill for secure final disposition of all residual wastes. (This may also include contract for controlled collection of recyclable materials from the hospital waste stream - packaging and other clean materials).

Checklist for an effective waste plan

Critical Elements of Present? If no, what is missing? Recommended Action to Meet Critical Waste Plan Yes /No Requirements

 Clearly identifies types of  YES  Develop Sharps Management Program waste needing special treatment with special  Other:

emphasis on sharps  NO management

 Evidence of Waste  YES  Establish waste segregation systems Segregation System?  NO

 Evidence of  YES segregation/minimization  NO  Develop hazardous waste minimization of hazardous chemical plan and program wastes?

 YES  Need to enhance safety of all waste  Overall safe collection of  NO systems all wastes?

 Defined safe protocols for  YES  Need to establish a defined sharps secure collection treatment  NO waste management program. See WHO and disposal of sharps guide. waste. (note: sharps includes needles, lancets, scalpels, blades, etc.)

 Collection of sharps waste  YES o Need to obtain rigid puncture resistant, should be in puncture  NO leakproof containers to collect sharps resistant plastic or metal wastes. containers. Cardboard is NOT acceptable.

 Defined policies to  YES  Need to establish purchasing policy to minimize volume and  NO support waste volume and toxicity toxicity of wastes reduction. See WB Guide generated? (purchasing policy)

 Worker Safety Protocols?  YES  Need to establish worker safety Evidence of training,  NO programs. See SIGN, WHO, WB evidence of use of documents personal protective equipment, evidence of consistent practice among workers?

 TB, Hepatitis B vaccine for  YES all workers handling waste  NO  Establish immunization plan and program for workers.

 Leakproof, color coded,  YES  Obtain proper collection containers for

labeled containers for  NO each waste stream. Seek special collection of each type of assistance for collection of hazardous waste? chemical wastes.

 Secure transport of wastes  YES  Need to obtain proper containers to within facility? E.g. closed  NO ensure safe collection and transport of collection carts, containers all wastes within facility.

 Waste Manager, or  YES  Designate someone to oversee waste someone designated to  NO programs, provide training as needed. oversee all aspects of See WHO guide, WB notel waste program/

 Adequate Treatment This section requires an area-by-area inquiry technologies to render special wastes harmless?  Obtain silver recovery technology or  Silver recovery - radiology  YES service  NO  Obtain solvent recovery technology or  Solvent recovery -  YES service laboratory  NO

 Obtain formalin/formaldehyde recovery  YES technology or service  Formalin/Formaldehyde  NO recovery - laboratory  Obtain autoclave technology or other  YES similar technology or service  Autoclave – facility-wide for  NO infectious materials  Identify and secure contract for burial or  YES cremation services.  Burial/cremation contract  NO  Identify hazardous waste firm for for body parts hazardous chemical wastes.

 Contracts with certified  YES  Identify neutralization process for hazardous waste  NO hazardous chemicals management firm(s) for chemical hazardous wastes

 Agreement with municipal  YES  Obtain agreement for secure landfill of or private landfill for secure  NO residual wastes final disposition of all residual wastes ( this can include controlled collection of recyclable wastes such as paper, metal, plastics, glass, cardboard) NOTE: With all queries above, note if there are contingency plans in the event the primary system or plan fails.

Annex 12: Code of Practice for Construction Workers

Part I: Code of Practice Part I: Code of Practice This provides general operational guidance to contractors.

Part II: Code of Conduct

This entails governance/management and regulation of social behavior of contractors at work.

1. INTRODUCTION

This code of practice provides guidance to contractors who will undertake construction of healthcare facilities associated with this project.

Construction work is work carried out in connection with construction, alteration, conversion, fitting-out, commissioning, renovation, repair, maintenance, refurbishment, demolition, decommissioning or dismantling of a structure.

Construction workers must always:

. take reasonable care for their own health and safety . take reasonable care that their acts or omissions do not adversely affect the health and safety of other persons, and . comply with any reasonable instruction and cooperate with any reasonable policy or procedure relating to health and safety at the workplace.

This Code should also accommodate provisions for grievance redress for workers in case of any complaint from direct or indirect workers.

2. MANAGING RISKS WITH CONSTRUCTION WORK

The first step in the risk management process is to identify the hazards associated with construction work. Examples of hazards include:

. collapse of trenches . falling objects, for example tools, debris and equipment . hazardous manual tasks . structural collapse . the construction workplace itself, including its location, layout, condition and accessibility . the handling, use, storage, and transport or disposal of hazardous chemicals . the interface with other works or trade activities . the physical working environment, for example the potential for electric shock, immersion or engulfment, fire or explosion, slips, trips and falls, people being struck by moving plant, exposure to noise, heat, cold, vibration, radiation (including solar UV radiation), static electricity or a contaminated atmosphere, and the presence of a confined space. . the presence of asbestos and asbestos-containing materials . the use of ladders, incorrectly erected equipment, unguarded holes, penetrations and voids, unguarded excavations, trenches, shafts and lift wells, unstable structures such as incomplete scaffolding or mobile platforms, fragile and brittle surfaces such as cement sheet roofs, fibreglass roofs, skylights and unprotected formwork decks . welding fumes, gases and arcs

3. SAFE WORK METHOD STATEMENTS (SWMS)

All persons who are involved in high risk construction work must develop and implement arrangements to ensure the work is carried out. This necessitates a SWMS, which is a written document that details high risk construction work activities to be undertaken, hazards or risks arising from those activities and measures to control the risks. All workers who will be involved in high risk construction work must be provided with information and instruction so they:

 know what to do if the work is not being conducted in accordance with the SWMS.  understand and implement the risk controls in a SWMS  understand the hazards and risks arising from the work

This information and instruction may be provided during general construction induction training, workplace-specific training or during a toolbox talk by the principal contractor, contractor or subcontractor.

4. OCCUPATIONAL HEALTH SAFETY (OHS) MANAGEMENT PLANS FOR CONSTRUCTION PROJECTS

An OHS management plan is a written plan that sets out the arrangements for managing some site health and safety matters. The intention of an OHS management plan is to ensure the required processes are in place to manage the risks associated with a complex construction project, as there are usually many contractors and subcontractors

involved and circumstances can change quickly from day to day. An OHS management plan must be in writing and must be prepared by the principal contractor before a project commences. It should be easily understood by workers (including contractors and subcontractors). It may not be necessary to communicate the entire OHS management plan to all workers; however, they must be made aware of the parts that are applicable to the work they are carrying out. The OHS Management Plan must contain: arrangements for consultation, cooperation and coordination . arrangements for managing incidents . arrangements to collect and assess, monitor and review SWMS. . names of persons at the workplace whose positions or roles involve specific health and safety responsibilities, for example site supervisors, project managers, first aid officers . site-specific health and safety rules and how people will be informed of the rules

While a OHS management plan is required for every construction project, a principal contractor may prepare a generic OHS management plan that applies to several construction projects, if the arrangements to manage work health and safety are the same for each construction project. However the principal contractor must review and revise the plan to ensure it addresses the risks of the actual workplace.

5. INFORMATION, TRAINING, INSTRUCTION AND SUPERVISION

All contractors and subcontractors must provide relevant information, training, instruction and supervision to protect all persons from risks to their health and safety arising from construction work carried out.

A range of activities can assist in ensuring people have the necessary knowledge and skills to complete the work safely, including general construction induction training and other training that may be specific to the workplace or the task the person is performing.

Information that might be provided includes workplace health and safety arrangements and procedures, such as for emergency evacuations. Information can be provided in various forms, including written formats or verbally, for example during workplace-specific training, pre-start meetings or toolbox talks.

General construction induction training provides basic knowledge of construction work, the work health and safety laws that apply, common hazards likely to be encountered in construction work, and how the associated risks can be controlled. Any person who is to carry out construction work must successfully complete general construction induction training, for example project managers and engineers, foreman, supervisors, surveyors, and labourers.

6. GENERAL WORKPLACE MANAGEMENT ARRANGEMENTS

The principal contractor must put in place arrangements for ensuring compliance with the following duties: . providing a safe working environment . Zero tolerance to Child Labour . providing and maintaining adequate and accessible facilities . providing first aid . preparing, maintaining and implementing emergency plans . providing workers with PPE, if PPE is to be used to minimise a risk to health and safety . managing risks associated with airborne contaminants . managing risks associated with hazardous atmospheres including ignition sources . storage of flammable and combustible substances . managing risks associated with falls, and . managing risks associated with falling objects.

The principal contractors may put in place arrangements for ensuring compliance with the above requirements through contractual arrangements, but they cannot rely only on these arrangements to ensure compliance. The principal contractor may also coordinate with other subcontractors, and check compliance whenever the principal contractor attends the construction site.

Part II: Code of Conduct for Contractors

Each employee including trainee or volunteer of a Contractor who have interaction with the project must sign this “Code of Conduct.”

In this Code, "Contractor" shall mean and apply to the contractor, its employees, sub-contractor, officers, agents, representative or those contracted through the Contractor to perform services authorized by the contract.

The contractor agrees to adhere to this Code of Conduct when providing services to this project. The Code of Conduct is in addition to all other contract requirements, policies, rules and regulations governing delivery of services. The purpose of the code is to protect vulnerable people from abuse, neglect, maltreatment and exploitation. It clarifies expectation of conduct of the parties and their employees, which includes administrative staff, care staff, support services staff and any others when interacting with the project.

Contractor, its agents or representatives authorized through it shall not abuse, sexually abuse or sexually exploit, neglect, exploit or maltreat any fellow employees or people from general public/ community. Additionally, no person shall cause physical injury to any other person.

The Contractor shall not by acting, failing to act, encouragement to engage in, or failure to deter from will cause any person to be subject to physical or mental abuse, sexual abuse or sexual exploitation, neglect, exploitation, or maltreatment. The Contractor shall not engage any person as an observer or participant in sexual acts.

Contractor understands and acknowledges that failure to comply with this Code of Conduct may result in corrective action, probation, suspension, and/or termination of contract.

Equally important to realise is that this Code also protects any person under the age of 18 years and any person 18 years of age or older who is physically or mentally handicapped or impaired due of mental illness, mental deficiency, physical illness or disability, or other temporary or permanent cause, to the extent that he is unable to care for his own personal safety.

1) Abuse shall include the following, but is not limited to: a) Harm or threatened harm, meaning damage or threatened damage to physical or emotional health and welfare of any person. b) Unlawful confinement. c) Deprivation of life-sustaining treatment. d) Physical injury including, but not limited to, any contusion of the skin, laceration, malnutrition, burn, fracture of any bone, subdural hematoma, injury to any internal organ, any injury causing bleeding, or any physical condition which imperils a person‟s health or welfare. e) Any type of physical hitting or corporal punishment inflicted in any manner upon the body.

2) Sexual misdemeanor will include, but not be limited to: a) Engaging in exploitive or manipulative sexual intercourse with any person. There will be zero tolerance to sexual misdemeanor including rape, defilement of minors/ sexual child abuse, sexual harassment and elopement. b) Taking indecent liberties with a person, or causing an individual to take indecent liberties with a person, with the intent to arouse or gratify sexual desire of any person. c) Employing, using, persuading, inducing, enticing, or coercing a person to pose in the nude. d) Employing, using, persuading, inducing, enticing or coercing a person to engage in any sexual or simulated sexual conduct for the purpose of photographing, filming, recording, or displaying in any way the sexual or simulated sexual conduct. This includes displaying, distributing, possessing for the purpose of distribution, or selling material depicting nudity, or engaging in sexual or simulated sexual conduct. e) Use of profanities and obscene language in communities or when instructing others.

3) Neglect may include but is not limited to: a) Denial of sufficient nutrition to any person. b) Denial of sufficient sleep to nay person. c) Denial of sufficient protective gear to any person. d) Failure to provide adequate supervision; leading to drug use in workplaces, accidents and impairment of employees. e) Failure to arrange for medical care and/or medical treatment for any person in an emergency. f) Failure to drive courteously at all times, leading to accidents. g) Failure to avoid damage public property. h) Neglecting public and employee complaints.

4) Drug abuse may include but is not limited to: a) Smoke in public or smoking in undesignated areas b) Consumption of alcohol while on duty/at work c) Use and trading in narcotics

5) Illegal trade activities without necessary licenses: a) Trade in protected fauna or flora species b) Trade in ivory or similar regulated wildlife products including game meat c) Trade in processed, semi-processed minerals and their ores

6) Financial exploitation will include, but is not limited to:

Utilizing labor of without paying for it, or at a non-commensurate financial rate/ wage.

7) Mistreatment will include, but is not limited to: a) Physical exercises, such as running laps or performing pushups, b) Unauthorized chemical, mechanical or physical restraints except, c) Assignment of unduly physically strenuous or harsh work. d) Failure to behave in a polite and courteous manner to the general public e) Requiring or forcing the individual to take an uncomfortable position, such as squatting or bending, or forcing people to repeat physical movements when used solely as a means of punishment. f) Group punishments for misbehavior of individuals except in accordance with the written policy. g) Verbal abuse: engaging in language whose intent or result is demeaning h) Denial of any essential service solely for disciplinary purposes i) Denial of visiting or communication privileges with family or significant others j) Requiring the individual to remain silent for long periods of time solely for the purpose of punishment.

Contractor agrees to document and report abuse, sexual abuse and sexual exploitation, neglect, maltreatment and exploitation as outlined in this Code and cooperate fully in any resulting investigation. Contractor shall prominently display a poster, notifying contractor employees of their responsibilities and to report violations and giving appropriate phone numbers.

Contractor/ Employee/ Volunteer/ subcontractor

Signed: …………………………………………. Date (dd/mm/yyyy):

Name: ………………………………………….

Annex 13: Overview of CERC

What is CERC?

Following an eligible emergency or crisis, the International Development Association (IDA) allows a country to rapidly reallocate funds from investment projects integrating a Contingent Emergency Response Component (CERC) to support recovery measures. In the case of crises, notably natural disasters and outbreaks, the activation of CERC can support recovery efforts, such as repair or restoration of basic physical assets, protection of critical development spending such as on health and education, creation of programs to jump‐start economic activity or the activation or scaling up of safety nets to mitigate the impact on vulnerable groups.

CERC Features

a) Eligible event: The World Bank defines as eligible an emergency or an event that has caused, or is likely to cause imminent, an economic impact and / or major negative social natural or human origin. The crisis or emergency should be declared officially, in reference to a well‐defined process (eg. declaration of national emergency, Level 2 grade of the WHO Emergency Response Framework, etc.); Amount: In the case of an emergency, the CERC allows countries to rapidly access financing of the undisbursed and uncommitted components of effective projects with the feature to support early recovery needs. The funds are reallocated from project‟s components to CERC;

b) Procedures: The use of funds follows World Bank procedures and policies. CERC uses the flexibility provided for in the emergency procedures of the WB, which allows a rapid restructuring of the project to meet urgent financing needs (and the use of simplified procedures);

c) Timing: The component is designed to support early recovery activities which can be implemented in a relatively short time period of 12 months; d) Institutional Arrangements: Activities funded by CERC are part of the project implementation, therefore the implementation unit is responsible for technical, fiduciary and safeguards aspects of the response.

CERC preparatory steps

To access the CERC, recipient countries must complete preparatory steps before being able to activate the component:

The inclusion of a Contingent Emergency Response Component in one or more IDA investment projects;

The adoption of an Emergency Operational Manual which governs the use of the funds at project level. It outlines the institutional arrangements, roles and responsibilities, as well as procedures governing the procurement, financial management, environmental and social safeguards, etc.

Preparation and disclosure of an emergency activities section at the Environmental and Social Management Framework (ESMF) which provides overarching guidance to screen, assess,minimize and mitigate the environmental and social risks and impacts associated with recovery activities to be financed by CERC.

CERC activation procedure

To activate the CERC, recipient countries must develop and submit to the World Bank an activation request letter indicating the Project funding amount and affected components, supported by:

1. A Contingent Emergency Response Implementation Plan (CERIP) providing details about the event, recovery strategy, institutional arrangements and proposed activities, including procurement plan. The CERIP is developed in consultation with the World Bank. Project Implementation Unit develops safeguard assessments and plans for the CERIP activities, where necessary, in line with the ESMF.

2. A copy of the Declaration of Natural Disaster Affected Area (dated) 3. A copy of the Assessment of the damages, losses and needs, such as the post‐disaster needs assessment or rapid impact assessment.

Implementation arrangements for the Emergency Response Plan

Once an assessment is carried out to inform the design of Contingent Emergency Response Implementation Plan (CERIP), several implementation arrangements can be selected to best facilitate the response.

1. Project Implementation Unit (PIU): The PIU is the responsible institution for technical, fiduciary and safeguard activities implementation. As the proposed CERIP is developed the PIU might need to increase its staff to address the surge demand of activities related to procurement, technical advisory for implementation, monitoring and evaluation, and safeguards.

2. Use of a third party: During CERIP preparation an assessment of implementation capacity of the PIU is carried out by the Bank with support to the Government. Based on the characteristics and requirements of the Emergency Response Plan‟s activities it is likely that an UN agency or NGO are best placed for implementing some or all approved activities. In such case, contracts and memoranda of understanding shall be signed under the Bank‐UN framework for delegating implementation to the selected service provider; however fiduciary and safeguards supervision remain a PIU responsibility.

3. Retroactive Financing: Under special circumstances and with the approval by the Bank a retroactive finance of emergency items already procured by the Government could be allowed. Eligible items are listed at the Positive list in the Operations Manual, and the procurement process must be conducted up to one month prior the CERC activation date. All approved items for retroactive financing shall be listed at the CERIP.

Annex 14: WHO Guide for Managing EVD Medical Waste

Annex 15: WHO guidance on WASH associated with EVD

Annex 16: COVID-19 emergency activities to be undertaken Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) Pillar 1: CASE MANAGEMENT Activate ambulance services to aid referral Orientation of Ambulance MoH MoH- 336.2162162 of suspected cases from community and Teams URMCHIP holding facilities to COVID-19 isolation Procurement of fuel for MoH MoH- 39956.75676 facilities rapid response ambulance URMCHIP services Assess public and private health facilities for Adapt assessment tools for MoH MoH- 141.8918919 COVID-19 readiness (including IPC COVID 19 URMCHIP capacity, on-site Oxygen production and supply, and logistics) on a quarterly basis. Assessment of Health MoH MoH- 30038.61004 Facilities URMCHIP Orientation of assessment MoH MoH- 236.4864865 teams URMCHIP Conduct surveillance for Hospital acquired Conduct surveillance for MoH MoH- 2702.702703 infections for COVID-19 in health facilities. Hospital acquired infections URMCHIP for COVID-19 in health facilities. Deployment of surge capacity staff Deployment of surge MoH MoH- 1556756.757 capacity staff URMCHIP Facilitate the setting up and decommission Needs assessment of MoH MoH- 6227.027027 of waste disposal systems (waste pits, waste disposal systems in URMCHIP incinerators, soak away pits). 16 RRHs Procurement of engineering MoH MoH- 864864.8649 services for Refurbishment URMCHIP and decommissioning of waste disposal systems in 16 RRHs Facilitate IPC training and information Conduct 2 day orientation MoH MoH- 34075.67568 provision for health care workers & support of health workers and URMCHIP staff in public and high volume private support staff in 16 RRHs on health facilities, including IPC committees IPC. and Provision of additional IPC supplies Facilitate mentorship, drills and exercises to Conduct a 2 day MoH MoH- 33902.7027 enhance skills and competencies in IPC in mentorship/ drill/ simulation URMCHIP isolation facilities exercise in all RRHs for the Isolation Team staff. Facilitate security personnel at the isolation Provide risk allowance for MoH MoH- 4151.351351 facilities security personnel at the URMCHIP isolation facilities Food assistance and/or specialized nutrition Food assistance and/or MoH MoH- 272432.4324 foods for suspects and health workers in specialized nutrition foods URMCHIP isolation. for suspects and health workers in isolation Have surge capacity to support case Orientation of surge MoH MoH- 9016.216216 management and IPC capacity staff per RRH URMCHIP Orientation of Health care workers in Orientation of Health care MoH MoH- 45374.51737 Regional Referral Hospitals, Severe Acute workers in Regional URMCHIP Respiratory Illness (SARI) sentinel sites on Referral Hospitals on management of suspect and confirmed Severe Acute Respiratory cases Illness (SARI) sentinel sites on management of suspect and confirmed cases Orientation of high volume private facilities Conduct 2 day orientation MoH MoH- 24729.72973 on detection and linking of suspect and of high volume private URMCHIP

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) confirmed cases to the designated isolation facilities on detection and facilities linking of suspect and confirmed cases to the designated isolation facilities Procure and or install WASH facilities for Procure and or install MoH MoH- 172972.973 priority health facilities and institutions WASH facilities in priority URMCHIP health facilities and institutions Training, simulation/drill exercises in 16 Conduct a 2 day MoH MoH- 129372.973 RRHs for 40 participants per facility mentorship/ drill/ simulation URMCHIP quarterly exercise in all RRHs for the Isolation Team staff. Sub total 3227289.884 Pillar 2: Coordination and leadership MoH MoH- URMCHIP Activation of National Task Force, district Convene 2 weekly MoH MoH- 292864.8649 task force and sub-committees. meetings of the District URMCHIP Task Force in 19 districts Convene weekly meetings MoH MoH- 22702.7027 of the COVID - 19 National URMCHIP Task Force Provide monthly MoH MoH- 20918.91892 communication (Airtime URMCHIP and data) Provide monthly MoH MoH- 648.6486486 communication (Airtime and URMCHIP data) for the NTF Renew licence for the MoH MoH- 10135.13514 Virtual Emergency URMCHIP Operation Center Conduct a simulation/drill exercise Conduct full field simulation MoH MoH- 22600 exercise URMCHIP Conduct table top exercise MoH MoH- 9729.72973 URMCHIP Conduct cross border coordination and Conduct crossborder MoH MoH- 23367.56757 collaboration meetings URMCHIP Deployment of the National Rapid Orientation and deployment MoH MoH- 262722.1622 Response Team of the COVID-19 National URMCHIP Rapid Response Team Deployment for surge staff Deployment for surge staff MoH MoH- 16216.21622 for data management and URMCHIP accountability Deployment for surge staff- MoH MoH- 97297.2973 Response URMCHIP Develop and issue information products Operationalize a MoH MoH- 1621.621622 including situational reports on COVID-19 Dashboard for COVID-19 URMCHIP Develop and issue information products Operationalize a MoH MoH- 2918.918919 including situational reports on COVID-20 Dashboard for COVID-20 URMCHIP Develop and issue information products Operationalize a MoH MoH- 194.5945946 including situational reports on COVID-21 Dashboard for COVID-21 URMCHIP Ensure remuneration and compensation of Conducting district risk and MoH MoH- 15979.72973 responders capacity assessment URMCHIP including at POEs and health facilities Provide risk allowance for MoH MoH- 72972.97297

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) responders URMCHIP Hold advocacy meetings at national level for Convene quarterly MoH MoH- 6918.918919 preparedness and response to COVID-19. breakfast meeting with URMCHIP donors Hold multi-stakeholder advocacy meetings Convene six monthly MoH MoH- 6486.486486 at national level for breakfast meeting for URMCHIP parliamentarians, religious leaders, cultural leaders and private sector Improve accountability for COVID-19 Hold accountability forum MoH MoH- 21729.72973 every quarter URMCHIP Monitor and supervise implementation of Conduct support MoH MoH- 57178.37838 the plan by districts supervision by district URMCHIP Monitor and supervise implementation of Conduct support MoH MoH- 26652.97297 the plan by the national level supervision by National URMCHIP level Orientation for surge staff Orientation for surge staff MoH MoH- 16756.75676 URMCHIP Orientation of multi sectoral and multi- Establishment and training MoH MoH- 86856.75676 disciplinary coordination at national and of district one health teams URMCHIP subnational level Sub total MoH MoH- 1095471.081 URMCHIP Pillar 3: Information and Communications Technology Digitalize mechanisms for self-declaration of Conduct training for MoH MoH- 2432.432432 travelers at PoE surveillance staff on the URMCHIP self-declaration form Digitalize mechanisms for MoH MoH- 5405.405405 self-declaration of travelers URMCHIP at PoE Digitalize mechanisms for self-follow-up for Data connection costs MoH MoH- 0 those under home isolation (Postpaid) URMCHIP Develop and deploy MoH MoH- 16216.21622 Android App for self- URMCHIP monitoring Implement Interactive Voice MoH MoH- 189189.1892 Response (IVR) URMCHIP Orientation of surveillance MoH MoH- 1216.216216 staff on self-monitoring staff URMCHIP Implement Budget tracking and activity Develop Budget tracking MoH MoH- 10810.81081 reporting system for the COVID-19 and activity reporting URMCHIP response system for the COVID-19 response Orient MoH staff, district MoH MoH- 3121.621622 staff and partners on the URMCHIP use of the budget tracking system Implement tele-medicine Delivery of medicines MoH MoH- 102162.1622 URMCHIP Development of protocol for MoH MoH- 4864.864865 remote care-conference URMCHIP package Orientation of staff MoH MoH- 10945.94595 URMCHIP Widen scope of implementation of eMeeting zoom connection costs - MoH MoH- 1297.297297 NTF URMCHIP

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) zoom connection costs - MoH MoH- 7783.783784 Subcommittee URMCHIP zoom connection costs - MoH MoH- 1013.513514 Trainings URMCHIP Sub total 356459.4595 Pillar 3: Logistics Enhance surge testing space in the UVRI Procure laboratory MoH MoH- 50675.67568 BSL3 equipment to enhance URMCHIP surge testing capacity at the UVRI BSL3 Enhance surge testing space in the UVRI Procure laboratory MoH MoH- 50659.45946 BSL4 equipment to enhance URMCHIP surge testing capacity at the UVRI BSL4 Enhance surge testing space in the UVRI Procure laboratory MoH MoH- 121621.6216 BSL5 equipment to enhance URMCHIP surge testing capacity at the UVRI BSL5 Enhance surge testing space in the UVRI Procure laboratory MoH MoH- 81081.08108 BSL6 equipment to enhance URMCHIP surge testing capacity at the UVRI BSL6 Facilitate scale up of eELMIS in all district Complete the orientation of MoH MoH- 250810.8108 and health facilities to strengthen supply MMSs in all districts URMCHIP chain coordination and management of MCM (1) Facilitation of point of entry supervisors Facilitation of point of entry MoH MoH- 472.972973 supervisors URMCHIP Medical equipment for ICU and Emergency Procure Medical equipment MoH MoH- 270270.2703 Units for ICU to functionalize URMCHIP Mbarara and Mbale Procure Medical equipment MoH MoH- 459459.4595 for Emergency Units URMCHIP New Testing Capacity at Sentinnel Sites Procure PCR equipment, MoH MoH- 394315.3378 Mbarara, Arua, Fort Portal and Mbale reagents and supplies for URMCHIP Sentinnel Sites in the Mbarara, Arua, Fort Portal and Mbale RRHs Procure additional motorcycles for Procure 50 motorcycles for MoH MoH- 160000 surveillance in affected districts the health regions URMCHIP Procure ICT supplies Procure desk top computer MoH MoH- 7500 , printers for and laptops for URMCHIP surveillance; laptops per RRH Procure desk top computer MoH MoH- 34500 ,printers for and laptops for URMCHIP surveillance; laptops per RRH Procure desk top computer, MoH MoH- 52500 printers for and laptops for URMCHIP s surveillance and case management Video Conferencing facility MoH MoH- 26000 URMCHIP Procure Sample Testing equipment for Procure laboratory MoH MoH- 83230.59122 CPHL - testing equipment for the CPHL URMCHIP

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) Procure laboratory MoH MoH- 75637.39865 equipment for the Mobile URMCHIP laboratories Procure Sample Testing equipment for the Procure laboratory MoH MoH- 72729.67905 UVRI - ABI equipment for the Uganda URMCHIP Virus Research Institute - ABI Platform Procurement of infrastructure and supplies Procurement of MoH MoH- 464975.2181 infrastructure and supplies URMCHIP Procurement of Isolation Negative Pressure Procurement of Isolation MoH MoH- 324324.3243 ALS Ambulances for referral of critical Negative Pressure ALS URMCHIP cases to Isolation facilities Ambulances for referral of critical cases to Isolation facilities (Entebbe & Naguru) Provide waste management facilities to Procure 4 Health care MoH MoH- 500000 regional referral hospitals to manage health waste facility to handle URMCHIP care waste during public health highly infectious waste in 4 emergencies (1) RRH Quantify and Disseminate the national Conduct National MoH MoH- 5459.459459 Medical countermeasure plan for public dissemination of the MCM URMCHIP health emergencies (2) supply chain plan Strengthen supervision (Supervision Emergency procurement of MoH MoH- 605405.4054 Performance Assessment Recognition 8 ambulances in addition to URMCHIP System - SPARS) for public health the existing fleet of car emergencies to promote monitoring, Training and mentor the MoH MoH- 254180.8108 traceability and accountability of public MMS on the new tool for URMCHIP health emergency commodities PHE-SPARS Transportation of samples to testing sites Facilitate transportation of MoH MoH- 459929.7297 samples to testing sites URMCHIP Sub total 4805739.306 Pillar 4: Mental Health and Psychosocial Support Deploy counsellors to communities and Deploy counsellors to MoH MoH- 203108.1081 affected families to mitigate psychosocial communities and affected URMCHIP effects of corona virus families to mitigate psychosocial effects of corona virus Supervise and monitor psychosocial Supervise and monitor MoH MoH- 31310.81081 services in the affected communities by the psychosocial services in the URMCHIP central team affected communities by the central team Train health workers and community Train health workers and MoH MoH- 176837.8378 resource persons to equip them with the community resource URMCHIP necessary skills for Psychosocial support persons to equip them with service provision the necessary skills for Psychosocial support service provision Sub total 411256.7568 Pillar 5: Risk Communication, Social Mobilization and Community Engagement Airing radio talk-shows on a weekly basis on Panelist allowance (x 2 MoH MoH- 3243.243243 major radio stations (airtime and panelists‟ people) - weekly for the first URMCHIP allowances) three months (4x3)= 12 x 5 radio stations = 60 Airing televised talk-shows Panelist allowances (2 MoH MoH- 11351.35135 people) x once a month for URMCHIP

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) 12 months x 5 TV stations Campaigns through branding of public Printing of stickers, IEC MoH MoH- 5405.405405 means vehicles materials URMCHIP Community dialogue meetings with high- Support sub-county level MoH MoH- 12411.89189 risk-communities or potential resistors - to RCSM-CE facilitators to URMCHIP ensure preventive community and individual travel to affected health and hygiene practices in line with the communities and facilitate national public health containment dialogue meetings (12 ppls recommendations per district x 4 -quarterly visits) Support VHT Quarterly MoH MoH- 116216.2162 review meetings URMCHIP Conduct district level risk and capacity Conduct quarterly national MoH MoH- 13864.86486 assessments at critical point of entry and meeting on risk assessment URMCHIP points of congregation (Entebbe, Kampala, with key stakeholders Wakiso, Busia, Tororo/Malaba, Katuna, Cyanika, Portbell, Mirama Hilla, Katuna, Mpondwe, all districts with Regional Referral hospitals and NIC sentinel sites (Kabale, Jinja, Lira, Fort portal, Mbarara, and any other emerging district at risk). Identify priority risk groups based on current surveillance data and baseline risk assessment Document lessons learned to inform future Field travel and MoH MoH- 13378.37838 preparedness and response activities. professional fees for Video URMCHIP coverage, journalist and photographers Engage with existing public health and Inter-religious councils at MoH MoH- 52297.2973 community-based networks, media, local district level - through URMCHIP NGOs, schools, healthcare service regional workshops and by providers, education sector, business and denomination (Anglican, travel Faith-based, Catholic, Muslim and Adventists) Inter-religious councils - MoH MoH- 2837.837838 national level conference URMCHIP Pharmacists and owners of MoH MoH- 14189.18919 private clinics ((one-day URMCHIP orientation x 100 ppts x 5 regions) Private sector, Corporate MoH MoH- 26351.35135 teams and entertainers or URMCHIP owners of mass gathering sites School owners (Head, MoH MoH- 69729.72973 Deputy and Senior Women URMCHIP teachers) - Hand-washing campaign in Schools Travel agents and hotel MoH MoH- 34864.86486 owners in the most at risk URMCHIP districts and districts with regional referral hospitals Uniformed forces and MoH MoH- 14189.18919 Uganda Wild Life Authority URMCHIP - how to conduct dialogues with different at risk groups

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) and reinforce communal health (one-day orientation x 100 ppts x 5 regions) Identify champions, develop messages and Airtime for one hour on 5 MoH MoH- 81081.08108 skits regional radio-stations x 12 URMCHIP talkshows Airtime for one hour on 5 MoH MoH- 30405.40541 regional radio-stations x 18 URMCHIP talkshows Engage local and national MoH MoH- 27027.02703 champions (comedians, URMCHIP musicians) to develop skits and messages Panelist allowance (2 MoH MoH- 111567.5676 people) monthly for 9 URMCHIP months (2x9)= 18 on 5 radio stations = 90 Precautionary advocacy and orientation of Deployment of national MoH MoH- 67412.16216 Mass Media practitioners at national and level teams to the high-risk/ URMCHIP district levels (owners of private and public most affected districts - to media houses including journalists, orient local journalists and Comedians and local musicians). owners of private media houses). Half-day orientation of MoH MoH- 4054.054054 Media/local journalists, URMCHIP Comedians, and Musicians (100 people per session)s Production and airing of televised Airing of TV advert 40 to 60 MoH MoH- 14594.59459 adverts/animations on COVID-19 seconds x 3 times a day x 3 URMCHIP days in a week (3x4) = 12 adverts a month for 3 months Provide regular press statements to media Bi-weekly breakfast MoH MoH- 48648.64865 houses (breakfast meeting with media) meeting with owners of URMCHIP Media houses, producers and programme directors Regular risk assessment through periodic Planning meetings; risk MoH MoH- 27027.02703 KAP assessments assessment scooping visits, URMCHIP field-research and post research meetings Strengthen coordination, build capacity and Support to national RCSM- MoH MoH- 4216.216216 leverage on existing communication CE sub-committees (once a URMCHIP resources, allies and implementing partners week x 15 people x 52 – multi-sectoral team of Risk weeks) Communicators on COVID-19 Strengthen coordination, build capacity and Recruit 4 surge MoH MoH- 136216.2162 leverage on existing communication staff/consultants to URMCHIP resources, allies and implementing partners reinforce RCSM-CE – multi-sectoral team of Risk activities at MoH/HPE (2) Communicators on COVID-20 and PHEOC (2) - to works closely with Epidemiologists and Surveillance teams (12 months * 10.5 m x 4 pple) Sub total 942580.8108 Pillar 7: Surveillance and Laboratory

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) Build national, regional and district level National Training of trainers MoH MoH- 1216.216216 capacity on COVID-19 surveillance (NTF, in border health for COVID- URMCHIP DTF, the DRRT, Health workers and 19 selected VHTs) National Training of trainers MoH MoH- 2027.027027 in COVID-19 surveillance URMCHIP including EBS Orient HW and Port health MoH MoH- 127540.5405 staff in COVID-19 URMCHIP surveillance using a One Health approach Orientation of border health MoH MoH- 36324.32432 committees (including URMCHIP immigration, revenue, trade and internal security officers at PoEs on identification of COVID-19 affected travelers) Printing surveillance MoH MoH- 1351.351351 training field guide URMCHIP Printing training field guide MoH MoH- 675.6756757 URMCHIP Review and adapt training MoH MoH- 3648.648649 field guide for border health URMCHIP with a focus on COVID-19 Review, refine, and finalize MoH MoH- 3648.648649 surveillance guidelines, URMCHIP training materials and reporting tools Sensitize VHTs/ MoH MoH- 891891.8919 Community volunteers on URMCHIP community based COVID- 19 surveillance Conduct district level risk and capacity Conduct quarterly national MoH MoH- 8108.108108 assessments at critical point of entry and meeting on risk assessment URMCHIP points of congregation (Entebbe, Kampala, with key stakeholders Wakiso, Busia, Tororo/Malaba, Katuna, Cyanika, Portbell, Mirama Hilla, Katuna, Mpondwe, all districts with Regional Referral hospitals and NIC sentinel sites (Kabale, Jinja, Lira, Fort portal, Mbarara, and any other emerging district at risk). Identify priority risk groups based on current surveillance data and baseline risk assessment Develop and implement a POEs public Technical support from the MoH MoH- 6810.810811 health emergency plan center URMCHIP Develop, print and disseminate case Develop materials MoH MoH- 2837.837838 definition, case investigation forms, line list URMCHIP and SOPs Print materials MoH MoH- 13513.51351 URMCHIP Facilitation of point of entry supervisors Facilitation of point of entry MoH MoH- 216000 supervisors URMCHIP Have surge capacity plans for surveillance Deployment of surge staff MoH MoH- 103783.7838 and lab URMCHIP Intensify screening and monitoring of alerts Active case search and MoH MoH- 364864.8649 at designated points of entry verification of alerts URMCHIP

Pillar or Areas of Intervention Activities to be Responsible Support Total World Bank Implemented Institution Cost Funding (US$) (US$) Conduct contact tracing MoH MoH- 364864.8649 URMCHIP Procure general materials and supplies for Procure general materials MoH MoH- 475000 laboratory diagnosis of COVID 19 and supplies for laboratory URMCHIP diagnosis of COVID 19 Provide full time staff for border health at Hire short term cotract staff MoH MoH- 788108.1081 the national and the respective POEs at the POEs URMCHIP Payment of allowances for MoH MoH- 665878.3784 staff at PoEs URMCHIP Training on specimen collection and Train 300 health workers on MoH MoH- 83108.10811 packaging - National Influenza staff, district specimen collection and URMCHIP staff, laboratory staff, clinical staff and packaging - National surveillance officers Influenza staff, district staff, laboratory staff, clinical staff and surveillance officers Sub total 4161202.703 Grand Total 15000000

Annex 17: Personal and public measures to control COVID-19 in Uganda

Annex 18: Guidance on GBV Case Management and the COVID-19 Pandemic

Overview This note aims to provide practical support to Gender-Based Violence (GBV) practitioners to adapt GBV case management service delivery models quickly and ethically during the current COVID-19 pandemic. It does not address all aspects of a gendered analysis that are necessary to create a robust response, nor is it a definitive set of guidelines. Rather, it is designed to be a “living” document, that will continue to draw upon the expertise of the global community in this new and evolving field. It assumes that users of this note already understand and are familiar with GBV case management.

Whilst the pathology of COVID-19 presents some unique challenges, GBV programming from other contexts of severely restricted access, such as conflict and natural disaster, offer important insights into how the provision of remote GBV case management support may be adapted to continue to offer a critical avenue of support to vulnerable women and girls.

GBV and COVID-19 There are reports of increases in GBV incidents in the countries most affected by the COVID-19 outbreak. For example, domestic violence organisations have observed that extended quarantine and other social distancing measures have increased the reports of domestic violence, as a result of household stress over economic and health shocks combined with forced coexistence in narrow living spaces (VAWG Helpdesk report, March 2020). There are also reports of a growing number of attacks on female healthcare workers, which have the potential to increase as health facilities struggle to provide adequate care to everyone who requires medical assistance (VAWG Helpdesk report, March 2020).

Given the increase in reports of GBV, ensuring that women and girls can access GBV support services remains a critical and lifesaving activity. At the same time, maintaining the health and wellbeing of GBV case workers and contributing to rigorous efforts to stop the pandemic are of critical concern, presenting a challenge to traditional modes of GBV service delivery. A flexible and adaptive approach is needed to ensure that life-saving services continue to be made available without compromising the safety of GBV caseworkers.

Case Management Services During COVID-19: A layered approach to risk management While some past infectious disease outbreaks provide valuable insights into how to maintain GBV case management, such models are not always directly transferable, given the unique pathology of COVID19. Unlike Ebola, COVID-19 is an airborne/respiratory virus, and although it has a much lower mortality rate than Ebola, it is in fact more contagious32, harder to detect and many carriers of the virus are asymptomatic33. The way in which

32 Zhanwei Du, Xiaoke Xu, Ye Wu, Lin Wang, Benjamin J. Cowling, Lauren Ancel Meyers. Serial Interval of COVID-19 from Publicly Reported Confirmed Cases. Emerging Infectious Diseases, April 2020

the virus is transmitted, its level of potency in a country at a particular time, the stark differences and exponential changes in national government responses all demand a higher level of flexibility, and a more layered approach to GBV case management service delivery than in past epidemics.

During the Ebola crises in West Africa and the Democratic Republic of Congo (DRC) for example, static case management services were largely maintained - more so when they were integrated within healthcare services. Humanitarian agencies and local women‟s groups3 were also able to provide limited outreach and case management through static safe space programmes to varying degrees by generally adhering to strict Infection, Prevention and Control (IPC) measures. Providing similar static case management services during all stages of the COVID-19 outbreak is likely to be significantly more challenging, and at certain stages, the risks might be too great or restrictions may make it impossible to do so.

This is not to suggest that case management is not possible within all stages of the COVID-19 outbreak; on the contrary, case management remains a critical service that is possible to continue in most cases as long as sufficient modification and adaptations are made to uphold public health guidelines. Decisions about whether to continue static, face-to-face case management services, scale down, or dramatically change in favour of other modalities such as remote case management, will depend on a number of factors including: • The strategy of national response to the coronavirus, i.e. containment, delay or mitigation. Each carry various levels of risks and restrictions which make some modes of service delivery more possible than others. • Resources (including donor flexibility) for the service provider to maintain stringent IPC standards at all stages of the pandemic, and in preparation for more advanced stages. • National government guidance and policies that affect freedom of movement and the ease of obtaining official permissions including formal exceptions required to operate static services in the event of national lockdown. • Risks and perceived risks for staff and others. It is critical to weigh actual risks not only to the health of staff, but to the health of others whom you may be exposing by carrying out your services (including movement to and from). In addition, perceived risks also affect staff and clients.

• Location of static services: GBV case management services situated within official clinical settings are more likely to be able to provide static, face to face services for the duration of the pandemic. • Organizational policies. Service providers interpret government guidance and policies in a more or less flexible manner which can influence service provision.

Understanding National Response Strategies Current national responses to COVID-19 can be roughly classified into three strategies: containment, delay, and mitigation34. It is important to note that all three strategies can run concurrently in any one territory, and that changes from one to the other might change in as little as 24-48 hours. Therefore, a high- level of preparedness is necessary in all countries, even those with zero or few confirmed cases. Given how rapidly responses are changing, service providers should put contingency plans in place immediately for each of the strategies.

Below is a quick description of each strategy and the type of impact that can be expected on case management services: • Containment: Normal public life is minimally affected as governments focus on early detection, isolation and care of people already infected with careful tracing and screening of their contacts. Static, face-to-face case management, with strict adherence to IPC protocols, is possible

33 Infection Control Today, Asymptomatic carriers of COVID-19 Make it Tough to Target. Accessed 18/3/2020 3 Discussions with GBV practitioners 34 Lancet, COVID-19: delay, mitigate, and communicate, March 2020

under this strategy. However, plans must be in place for a rapid escalation in number of virus cases which may prompt governments to quickly change strategy and take more aggressive action to reduce the spread of infection. This includes identifying alternative models and beginning to train staff and actively communicating with clients about possible changes to come.

• Delay: the aim is to slow the spread of the virus and push the impact away till a time when a country‟s health service can cope with the spread. Social distancing strategies, closure of education institutions, prohibitions on large gatherings, and reduction in the use of public transport are common and are implemented with varying degrees of enforcement. Static, face-to-face case management may be possible depending on the location of the service, the ability to resource and provide effective protection of case workers, and the severity of national policies on freedom of movement and assembly. Action should be taken at this stage to include other modalities of delivering case management, and to train staff and clients alike for continued changes.

• Mitigation planning for widely established infection: As seen in China, Italy and Iran, this strategy is deployed by governments seeking to stem widespread infection during a prolonged pandemic in which high levels of the population are infected. This may involve more directive “lockdowns” or “sheltering in place”, where movement is more tightly restricted and monitored, transport arteries may be blocked, and possibly permissions required. Maintaining static, face-to-face case management services outside health care facilities will be extremely challenging, or even impossible.

Table 1 below summarises the common national strategies that are emerging, the features of each, their impact on GBV case management and possible modalities for delivering case management services. These are not directive for every context. In each context, teams must weigh their specific circumstances and current public health guidance.

Immediate Key Actions

1. Immediately put in place Infection, Prevention and Control (IPC) measures in accordance with standards at all service delivery points. Coordinate with Water, Sanitation and Hygiene (WASH) and other relevant sectoral teams. a. In places where you are meeting clients face-to-face, set up hand-washing stations and/or make hand sanitiser available immediately upon entrance. b. If “thermoflash” thermometers are accessible, it may be appropriate to use them to check temperatures of those accessing services. Consult with health programmes about whether this protocol is suggested in your context. Note that the use of thermoflash can be scary to those who have never seen them before, and particularly to children. It might be necessary, therefore, to conduct some awareness-raising and communication about thermoflash so that people know what to expect and are not scared away. c. Ensure adequate distancing in activities so that women and girls can access services and be kept 2 meters apart, and without large crowds forming (follow the guidance in your area for limiting numbers). d. Put in place measures to ensure that Women and Girls‟ Centers or other spaces where caseworkers operate are not crowded and are able to adhere to distancing guidance. This may include putting a cap on the number of women and girls accessing the service at one particular time, and/or marking spaces for mats on the floor/ chairs on the ground, etc. e. Do not send caseworkers into crowded areas or situations where they cannot maintain the suggested IPC protocols or suggested distancing. f. Ensure all caseworkers have access to hand-washing stations, hand sanitiser, and all the tools they need to continue to provide support, for example mobile phones and mobile phone credit.

2. Communicate openly with women and girls about COVID-19 and any changes or potential changes in your methods of service delivery. a. Re-assure clients that support services will still be available in some capacity, even if the modality changes, and that they will not be alone. Be careful to listen to their fears, questions, suggestions, as well as what will work best for them. b. Develop quick discussion guides and communication materials for discussing COVID19 with your clients and women and girls in your programmes: i. Emphasise the importance of listening to clients, as well as giving out messages. Use your space to listen to women and girls and to ask questions to better understand what they know about COVID-19, as well as what their concerns and fears are and their suggestions for how we improve our response. ii. Make sure that messages around COVID-19 and IPC measure evolve over time and meet the needs of your clients, women and girls. iii. Share any relevant information such as changes in services, hotline numbers, and how to reach relevant service providers in case of a change.

3. Meet with your team to discuss best options for remote support to survivors and remote support to staff. It is possible to maintain some level of support for survivors and staff alike, even under extremely restricted circumstances. It is important that staff are engaged actively in decision-making so that they feel a sense of ownership, control, and connectivity during the rapidly changing crisis. This is about more than supervision, it is about support.

Discuss with staff what more you can do support them personally, as well as professionally. Check in regularly as the situation evolves. 4. Keep up to date on the latest guidance in your region. It is essential to keep up-to-date with the latest guidance being given in your specific context and also to recognise that this will change on a day- to-day basis. Planning ahead is important, as is making sure your actions are aligned with what is happening in your particular communities. For example, if no restrictions have been placed on movement or gatherings in the areas where you work and suddenly your team stops all programming entirely, you might cause further fear and uncertainty. However, if you are ready to take certain steps based on public health guidance and feel that others are moving too slowly, do what your team believes is best for the safety of your clients and each other. Follow protocols for infection, prevention and control at each stage and be ready for the situation to change quickly.

Preparing for Sudden Changes, Including “Lockdown” or “Quarantine.” Government responses to COVID-19 are changing rapidly and dramatically, perhaps more so than any other outbreak. Therefore, even countries which do not currently have confirmed cases, should consider the following:

1. Begin safety planning with current clients for situations of quarantine, lockdown, or “shelter-in-place”. Help your clients to prepare for the possibilities. Help them to feel a sense of control in a chaotic moment. Key issues and measures to explore include: a. Do they have someplace safe to stay that is not with the abuser? b. If not, are there any steps they can take to help minimise harm at home? c. Provide them with phone numbers of caseworkers, hotline, or other support providers that they can keep safely. If they have phones, they may store the number under a code name, or you may print tiny cards that can easily be hidden. d. Brainstorm ways that they can safely call for help and access support. e. Explore ways that they can plan with their neighbors to signal that they need support.

2. Ensure continued safe storage of sensitive documentation. In the event that your offices shut, consider the safest ways to store documentation without putting anyone at risk. Primero/GBVIMS+ for case management offer options for digital storage, including on mobile phones. Ensure that organisations have developed and implemented data protection protocols with paper and electronic file evaluation provisions35. Key issues and measures to explore include: a. If leaving your office, will that documentation be locked and safely stored? Is it possible that someone might gain unauthorized access? b. If moving to remote support, how will you document cases? Is it safe to store information on phones, tablets, or paper?

3. Develop quick and clear new case management protocols with staff. If you move to remote support, how will it work? For example: a. Which phones and phone numbers will be used for case management? b. How often will staff contact current clients? How will staff be reachable to clients? c. Will you be accepting new calls/clients in addition to following up with current clients? d. How will calls be documented and followed upon?

35 See template of the GBVIMS Data Protection Protocol: http://www.gbvims.com/wp/wpcontent/uploads/DATA-PROTECTION- PROTOCOL.pdf

e. Will there be a staff rotation to ensure coverage? f. Will this be safe for staff?

4. Consider modalities for remote supervision. This refers to supervision of case management. This may include remote individual supervision and peer-to-peer or group supervision through online platforms and/or phones. Case file review can be enabled for remote supervision through rollout of digital case management tool, such as Primero/GBVIMS+ which includes functionality such as flags, case plan/closure approval, remote case file review and automated production of key performance indicators (KPIs). Remember: supervision is not the same as support. Supporting the overall wellbeing, health, and stress management of staff is of utmost first priority. This must be in place before you can introduce new forms of staff supervision.

5. Strengthen capacity and confidence to provide remote support a. Review guidelines on supporting survivors through digital and remote support. There are various types of guidance around using technology to communicate with survivors during a public health crisis, including text messaging, calls, online support, to ensure safe and ethical connections. Examples can be found below in the resources section. Review as needed to ensure ethical programming. b. Conduct rapid training/skills-building for staff on any new technology to be used for support. Teams may need to get acquainted with systems used for hotlines, online service provision, and apps (e.g. Primero/GBVIMS+). Reach out for support to relevant actors who are managing or have experience with the platforms being used e.g. GBVIMS global team, etc.

6. Prepare for possible closure (temporary or long-term) of physical locations for case management. It may be necessary to close Women and Girls‟ Centers or other physical spaces where you are providing case management services. This may be temporary or for an indefinite term. You may need to take steps similar to programme exit in this case (resources around exit strategies can be found in the Resources section below). Consider questions such as: a. Are there any outstanding payments that need to be made for the space? b. Can items be left there safely, or is it necessary to remove them? c. Will anyone access the space for any reason during closure? d. Are there any risks involved to closing the space? How can you mitigate these? 7. Coordinate with other services providers. Solidarity is critical in adapting to the new situation. Information is also crucial on what will be available to survivors and how to ensure coordinated and safe access to shelters and law enforcement authorities. 8. Inform communities of possible changes ahead. Be sure to communicate possible changes with clients as well as communities, in order to maintain trust. 9. Communicate with donors about changing needs. Begin communicating with donors immediately about changes in case management programming and funding needs, including preparations for worst-case scenarios. Request greater flexibility of resources and rapid mechanisms for ensuring you have the resources you need.

Modalities of Adapted and Remote Case Management: In situations of containment, when limited movement and contact is a viable option, you may be able to continue face-to-face support, while observing IPC protocols. You may also consider switching to a health-center based caseworker model described below. This is also the opportunity of train all frontline workers on the GBV Pocket

Guide as they may face disclosures of violence. In situations of delay, mitigation, or any severe restriction of movement and access, the following are options for continuing case management support remotely:

1. Health-centered based caseworkers. When movement of people is limited, and the majority of efforts are focused on supporting healthcare systems, basing a caseworker at a health center might be a good option. The caseworker could be available to support both women and girls who are infected with Coronavirus and survivors who report to the hospital. This model was used during the Ebola response in DRC by GBV actors. There is a need to work closely with health teams to ensure that this is a safe and viable option. You need to be careful not to be seen to be creating an extra burden for staff, but rather GBV should be framed and recognised as a life-saving service in itself. 2. Mobile phone case management. Caseworkers may be able to provide case management support by mobile phone. In this case, consider the following:

a. Provide additional sim card and/or mobile phone to caseworkers solely for the purpose of providing support. b. Electricity sources: What kind of access to electricity do they have? Is maintaining charged phones a challenge? Can you provide battery packs or solar chargers? c. Consider the safety of making and receiving calls for staff, as well as safety of making and receiving calls for clients. There is a risk that conversations might be overheard and confidentiality breached. d. How is data collected? We want to avoid caseworkers storing paper forms at home or in locations that are unsafe. Consider rolling our digital case management tools such as Primero/GBVIMS+.

3. Hotlines. If a hotline exists already, discuss with that provider how you may link into that by offering staff support, sharing their number, etc. If there is not, you may consider buying additional mobile phones and creating a shift schedule for caseworkers. Remember that if caseworkers are also on lockdown, they will have duties at home and stress of their own. Therefore, it is important to discuss what is feasible and safe.

4. WhatsApp communication. This may be the preferred option for communication both by survivors and case workers. You need to take into account staff stress, home duties, safety, access to electricity and internet, as mentioned above. 5. Limited rapid or mobile response team. Your organisation may maintain a rapid response team during the outbreak with limited staff involved in providing essential services, in accordance with national strategies and IPC protocols. If this is the case, you may advocate for a caseworker to be on that team, if the benefits outweigh the actual and perceived risks.

15 Shelters and COVID-19 If you are running case management services out of a shelter for women, it is important to follow all IPC protocols and emerging guidance. Specific guidance for managing shelters during the outbreak is available at: https://vawnet.org/news/preventing-managing-spread-covid-19-within-domesticviolence-programs

16 Prioritising Duty of Care to Staff Caring for staff and prioritising their wellbeing is the foundation of any other action. Put systems in place to ensure that staff are getting the support they need and to prioritise this as the outbreak continues. This includes:

1. Creating space to ask staff about their concerns, their needs, and their ideas for moving forward. Give time to talk freely, whether about work, or the situation more generally. Do this at every stage of the outbreak, whether in-person or continuing remotely. 2. Observing IPC protocols; work to reduce risk as well as perception of risk. 3. Sharing resources for managing stress and maintaining emotional wellbeing. This can be documents with links to resources, sharing one simple self-care exercise per day via text/WhatsApp group, phone numbers for accessing psychological support, etc. 4. Ensuring that staff have phone numbers and information about support services that are available to them. 5. Checking in regularly by phone or WhatsApp as a form of emotional support (different from supervision). Creating chat groups or other relevant fora for staff to connect and support each other. 6. Sharing resources online that staff can use to continue to build their skills. e.g. the Rosa App by International Rescue Committee (IRC), GBVIMS podcasts and videos, etc.

17 Key Principles and Considerations

1. Prioritise the safety and wellbeing of all staff and clients. This is true in any GBV programme and remains true during the COVID-19 response. 2. Solidarity with the most vulnerable. Some clients will be more vulnerable than others, and some community members more vulnerable. Remember that social distancing and other measures are not just about protecting clients, but about everyone doing their part to protect others. Keep this in mind when making decisions. For clients who are particularly vulnerable, prioritise early safety planning for changing conditions and regular follow-up. 3. Focus on humanity over productivity. Remember that these are stressful times, and that the changes and uncertainty add to that stress for staff, their families, clients and communities. As you make changes to programming, do not over-emphasise the need for seamless transition and continued productivity. Staff will likely need time to slow down, to figure out what the next days and weeks look like and to manage stress alongside continuing work. Help everyone to take a breath and assure them that this is ok. 4. Be prepared, not panicked. This paper highlights the importance of preparing for all scenarios urgently, expecting the possibility of rapid changes. However, changes should be planned for as calmly as possible, and presented as proactive steps rather than panicked reactions. 5. Advocate for increased gendered analysis across the response. This paper focuses on GBV case management. However, a gendered analysis is essential to a strong response for all communities and in particular to women and girls. Advocate in relevant fora and provide guidance as needed to build a more gendered response in your area.

Resources on GBV Remote Support:

How to Support Survivors of Gender-Based Violence When a GBV Actor Is Not Available in Your Area: A Step-by- Step Pocket Guide for Humanitarian Practitioners https://bit.ly/2WqrT9f Guidelines for Mobile and Remote Gender-Based Violence (GBV) Service Delivery https://bit.ly/2xKsFUe Using Technology to Communicate with Survivors During a Public Health Crisis https://bit.ly/3b6LMX5 Chat with Survivors: Best Practices https://bit.ly/3deRXu8 Texting and Messaging with Survivors: Best Practices https://bit.ly/33vOK4G Communicating with Survivors using Video: Best Practices https://bit.ly/3a553rI Guidance Note on Ethical Closure of GBV Programmes https://bit.ly/2Wye4pz

Resources on GBV and Infectious Disease Outbreaks: Overcoming the „Tyranny of the Urgent‟: Integrating Gender into Disease Outbreak Preparedness and Response https://doi.org/10.1080/13552074.2019.1615288 The Effect of the 2014 West Africa Ebola Virus Disease Epidemic on Multi-level Violence Against Women https://www.researchgate.net/publication/306902936_The_effect_of_the_2014_West_Africa_Ebol a_virus_disease_epidemic_on_multi-level_violence_against_women Ebola Publications: Case management, Infection Prevention and Control https://bit.ly/2vxEqN6

Resources Specific to COVID-19: GBV Guidelines Resource Hub https://gbvguidelines.org/en/knowledgehub/covid-19/ Technical Note on Protection of Children During the Coronavirus Pandemic https://alliancecpha.org/en/system/tdf/library/attachments/the_alliance_covid_19_brief_version_1 .pdf?file=1&type=node&id=37184 Staying Safe During COVID-19 https://www.thehotline.org/2020/03/13/staying-safe-during-covid-19/ The COVID-19 Outbreak and Gender: Key Advocacy Points from Asia and the Pacific https://bit.ly/2WtyC2i Coronavirus: Five Ways Upheaval is Hitting Women in Asia https://bit.ly/2xc4JZz COVID-19: The Gendered Impacts of the Outbreak https://bit.ly/2xTfsJ1 The COVID-19 Pandemic & Digital Services https://bit.ly/2xJG3rJ Gender and the Coronavirus Outbreak https://bit.ly/394ZDvD Gender Implications of COVID-19 Outbreaks in Development and Humanitarian Settings: Executive Summary https://bit.ly/2QtFfxP Gender Implications of COVID-19 Outbreaks in Development and Humanitarian Settings https://bit.ly/2U1UbVV COVID-19: Coalition Guidance for Programmes https://bit.ly/3a6iWWH COVID-19: The Gendered Impacts of the Outbreak https://bit.ly/2IXNduT Impact of COVID-19 Pandemic on Violence Against Women and Girls https://bit.ly/2xbcM92

The GBV AoR Help Desk

The GBV AoR Helpdesk is a technical research, analysis, and advice service for humanitarian practitioners working on GBV prevention and response in emergencies at the global, regional and country level. GBV AoR Helpdesk services are provided by a roster of GBViE experts, with oversight from Social Development Direct. Efforts are made to ensure that Helpdesk queries are matched to individuals and networks with considerable experience in the query topic. However, views or opinions expressed in GBV AoR Helpdesk Products do not necessarily reflect those of all members of the GBV AoR, nor of all the experts of SDDirect‟s Helpdesk roster.

Annex 17 Recommendations to address differentials between men and women during implementation

The Table provides a non-exhaustive list of measures for HNP COVID-19 response projects to address differentials between men and women during implementation. Activities should be adapted to context. Issue Recommendations

• Sexual • Provide safe transportation, psychosocial support and mechanisms to report abuse for health Exploitation, workers. Abuse and Harassment • Ensure that essential medicines like PEP and emergency contraception available through health systems and there is a system for referrals to services outside the health system for other support. • This may require updating referral pathways. • Train frontline health workers on response and referral of GBV cases reported to them in the • context of service provision. Does the intervention consider where women and children go if they need to report a case of GBV? If they need protection? Use social media, radio, etc. to embed messages on healthy • conflict resolution, healthy parenting, stress and anger management in community and other Prevention awareness campaigns. Include information on how to seek services during periods of social and response distancing. to the risk of • Consider using technology and mass communication to diffuse information on healthy conflict Gender-based resolution, healthy parenting, managing stress and anger in a positive way. Saturate Violence (GBV) communities with empathy messages to apply within the home and with others. • Harassment Increase funding for and the capacity of helplines for GBV reporting/referrals (likely to be flooded). • Provide people working in service provision and helplines with flexible working hours, physiological support and space for retreat. • Provide funding to service providers, including NGOs and community-based organization, legal aid service providers, case management services, and shelters, who will need to invest in technology to support survivors because of social distance and quarantine measures. • Train police to deal with cases by using non-physical techniques such as talking to people to dissipate issues. • Respond to the increased need for mental health and psychosocial support building on existing services, local care structures and prioritizing coordination. • Integrate mental health and psychosocial considerations into all response activities. Establish measures to reduce the negative impact of social isolation in quarantine sites. • Open lines of psychosocial support; consider volunteer psychologists to provide online therapies/ help with hotlines. • Mental health Mobilize private sector specialists who may not be employed to join the public sector to help. • Use WhatsApp, social media and other forms of technology to set up support groups/maintain social support, especially for those in isolation. • Train all frontline workers and non-health workers in quarantine sites on essential psychosocial care. • Offer psychosocial support to health workers, GBV survivors, and communities

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Annex 19: Technical Note on Use of Military Forces to Assist in COVID-19 Operations Suggestions on how to Mitigate Risks

It is common practice for Governments to utilize military or security personnel during public health emergencies. The ability to do this, and the requirements relating to such mobilization, are often set out in executive orders or instructions. A „public health emergency‟ will usually be defined under national law. For example, the US Department of Defence (DoD Instruction 6200.03, March 28, 2019) defines a public health emergency to include “the occurrence or imminent threat of an illness or health condition that poses a high probability of a significant number of deaths, serious or long-term disabilities, widespread exposure to an infectious or toxic agent, overwhelmed health care resources, or severe degradation of mission capabilities”.

For the reasons set out in section 1 below, it is expected that military or security forces will be utilized in different ways in response to COVID-19. They may be used directly to carry out activities in a World Bank-supported project. Or they may be mobilized more generally to implement Government programs, which are also supported by the Bank. Where military/security forces are utilized, either directly or indirectly, in connection with Bank-supported operations, questions will arise about the risk of the operation. Is it automatically high or are there effective ways of mitigating the risk? This guidance sets out suggestions for due diligence and mitigation measures to address the risk.

1. WHAT ARE THE POSITIVE ASPECTS ABOUT USING THE MILITARY? Where relevant, consider the following and document relevant details:

 Human rights: Depending on the country, military personnel may be aware of the need to respect human rights and received relevant training.  “NBC” capabilities: Many military forces have nuclear, biological and chemical capabilities. They may have existing biological defense capabilities e.g. ability to deploy with personal protective equipment (PPE); training in decontamination; procedures or advice on how to carry out relevant activities.  Medical expertise: Medical and other professionals within the military are likely to be trained to deal with medical emergencies, and therefore may be better able to cope in situations in which there may be mass casualties.  Disciplined response: Generally, military personnel are expected to respond in a disciplined manner to commands and will have capabilities which will be useful in these types of emergencies (medical, engineering, construction).  Civic action programs: Military may also have specific civic action programs and infrastructure to support these (e.g. mobile clinics/communication procedures).

2. WHAT ARE THE THINGS TO WATCH FOR?

(a) Diversion of materials, aid and assistance: Diversion can take the form of confiscations and re-use, misappropriation and theft. While a certain level of diversion may be inevitable in certain circumstances, this issue is likely to present reputational issues (especially when the crisis dissipates).

(b) Allegations of human rights violations: This will be a risk, including as it relates to Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH), and the Bank needs to be clear and transparent about what measures are being adopted to minimize these risks. Tools that should be considered include the ESF Good Practice Note (GPN) on Use of Security Forces, on SEA/SH, and the IFC Good Practice Handbook on the Use of Security Forces: Assessing and Managing Risks and Impacts.

(c) Putting World Bank staff at risk: This is particularly a concern where military/security forces are likely to be undisciplined. The risk may be heightened when Bank staff are trying to address the risk of diversion

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referred to above. While staff may try to address this risk by avoiding direct interaction with the military, this is not likely to be feasible in a project setting.

(d) International media comment and reaction: This will be a challenge, and it may not be possible to avoid negative comment entirely. It is important to be transparent about the activities the World Bank is supporting and the mitigation measures that are being implemented to address risks.

3. WHAT ARE THE WAYS TO ADDRESS THE RISKS?

(a) Get a view of the reputation and capability of the military: Talk to those who might have up to date and accurate information: e.g. the Defense Attaché at the relevant Embassy; the US or UK Government; refer to Jane‟s Defence Weekly.

(b) Identify the structure under which the military will be operating: While they will continue to abide by their own rules and procedures, it is likely that the military will also be subject to relevant national requirements relating to the public health emergency and the specific activities that they are required to carry out e.g. instructions issued by public health officials. In the context of a Bank-supported operation, it is good practice to document (as far as possible) the structure under which the military are operating, including the chain of command, with specific reference to the activities they will or are likely to carry out (see paragraph (i) below).

(c) Clarify who is responsible for human rights issues nationally: Many countries have a Human Rights Commission. If such commissions do not exist, there is usually an Ombudsman, Human Rights office or inspector general at the national level with jurisdiction to deal with such issues. Identify the relevant parties and consider whether it would be appropriate to consult them for advice.

(d) Identify other specialized parties and ask for advice: There are both national and international NGOs which follow and support these issues (e.g. Human Rights Watch (HRW), Amnesty). There is also the International Committee of the Red Cross (ICRC) and the International Crisis Group. Identify relevant parties, with reference to the context and nature of the operations, who may be in a position to provide valuable advice.

(e) As required under the ESF, cooperate with relevant stakeholders on a risk assessment: Carry out a risk assessment to identify the specific risks associated with the proposed use of military. This assessment needs to be conducted with those that are involved in the operation, including Government counterparts, to ensure that an accurate picture of the risks emerge, that appropriate mitigation measures are identified and that both the risk assessment and the mitigation measures are owned by the project and the Government.

(f) Be transparent about what the World Bank is requiring to mitigate the risks: Document this, setting out key aspects in the ESRS and other project documentation. Consider the following:  procedures relating to: e.g. risk assessment; how allegations of HR/SEA/SH violations will be dealt with, including through the project Grievance Mechanism (GM); preventing diversion of materials, aid and assistance (build on existing requirements)  presence of World Bank representatives/third party monitors on the ground  cooperation with specialist institutions/NGOs/Government agencies  specific obligations set out in the legal agreement and (if possible and appropriate) a Memorandum of Understanding (see paragraph (k) below)  monitoring and reporting

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(g) Consider asking a credible party to act as an observer/third party monitor: This can be considered under the ESF provisions for third party monitoring as noted in ESS1 and ESS10, as well as the ESF Good Practice Note on Third Party Monitoring. Relevant groups with experience in this field will depend on the context, and may include the parties referred to in paragraph (d) above.

(h) Establish a procedure to be followed in cases of allegations of HR/SEA/SH violations or misbehavior: This should reflect the ESF Good Practice Note on SEA/SH and may include reference to the institutions referred to in paragraph (c) above. Include a specific HR and SEA/SH procedure in the project GM to address these allegations and identify specific individuals who have the expertise to address such allegations credibly. Understanding relevant Code of Conduct (CoC) requirements pertaining to such behavior is important, and, where necessary, improving the form and substance of such CoC.

(i) Be clear on what the military will do: Identify the activities and set them out clearly in the legal agreement: e.g. construction, enforcing quarantine restrictions, distribution of medical supplies or vaccines, distribution of other supplies. This will support a more accurate risk assessment. Note that in some circumstances, what could otherwise be viewed as inappropriate behavior by the military (or at an extreme, a possible abuse of rights) may be authorized and necessary in situations of a public health emergency. This will depend on the activities that the military is required to carry out and will be particularly relevant where they are required to enforce public order or quarantine restrictions.

(j) Set out specific requirements as covenants in the legal agreement and in the Environmental and Social Commitment Plan (ESCP) as appropriate: The provisions should set out the „ground rules‟ for military engagement, including: (i) requirements to comply with ESS4; (ii) reporting obligations (specify on what, how often, to whom); (iii) specific prohibitions e.g. no child labor, no forced labor, restrictions on what military personnel under the age of 18 can do (if anything); (iv) health and safety requirements; (v) Code of Conduct (CoC) type obligations; (vi) requirements for the GM; (vii) training required and how often (specify on what – e.g. Voluntary Principles on Security and Human Rights, interactions with the community, operation of the GM, use of personal protective equipment (PPE), CoC).

(k) Where possible, and if not already covered by applicable law/regulation, the Government should consider executing a Memorandum of Understanding (MoU) with the military: This should reflect the „ground rules‟ set out in the legal agreement (see paragraph (j) above). An example of a MoU is available in the IFC Good Practice Handbook on the Use of Security Forces: Assessing and Managing Risks and Impacts. Even where it is not possible for individual military personnel to sign a CoC, the requirements should be set out in the MoU, and training should cover these obligations (amongst others).

ANNEX

Set out below is suggested wording on HR/SEA/SH:

1. Prior to deploying military or security personnel, the [Borrower/Recipient] shall take measures to ensure that such personnel are:

(i) screened to confirm that they have not engaged in past unlawful or abusive behavior, including sexual exploitation and abuse (SEA), sexual harassment (SH) or excessive use of force;

(ii) adequately instructed and trained, on a regular basis, on the use of force and appropriate behavior and conduct (including in relation to SEA and SH), as set out in the [Training Procedure, Project Operational Manual, ESMF, Security Management Plan, MoU ]; and

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(iii) deployed in a manner consistent with applicable national law.

2. The [Borrower/Recipient] shall promptly review all allegations of unlawful or abusive acts of any military/security personnel, take action (or request appropriate parties to take action) to prevent recurrence and, where necessary, report unlawful and abusive acts to the relevant authorities.

Set out below is suggested wording on reporting: Frequency of reporting will depend on the context and the risks associated with the activities the military is carrying out, and may be required monthly, weekly or even daily. Requirements should include:

 Immediate reporting (within 24 hours) of any serious incident  A written weekly or monthly report (depending on the risk) covering: o status of activities being conducted by the military o training conducted (specifying subject matter) o current status of review of serious incidents (if any) and any relevant reporting o a summary of any minor (but reportable) issues, suspected incidents or potential issues o details of any incidents involving use of force or weapons o details of upcoming activities which may pose a risk (e.g. distribution of supplies) and measures being put in place to reduce such risk o lessons learnt, to inform conduct of future activities

Other reference documentation: The International Code of Conduct under the Montreux Document. While this relates to private security, it contains useful material.

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Use of Military in COVID-19 Operations: Version 1: Suggestions for Due Diligence and Mitigation March 25, 2020