Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038) contribute to increasing the preparedness of the population in the event of a climate-related disaster. Finally, the widespread loss of power may seriously threaten the COVID-19 vaccine cold chain as vaccine conservation standards will be impacted. Therefore, as an adaptation measure, some of the cold chain equipment purchased will be off-grid solar equipment/supplies such as solar powered fridges and freezers that will provide reliable 24/7 power and efficient cooling. The NDVP includes measures to deal with any unexpected disruptions to the vaccine supply chain, distribution and storage from climate change impacts and other unexpected disasters (i.e., power outages from flooding and extreme heat).

**81.** **The project includes activities from which adaptation co-benefits are expected.** These activities include technical
assistance to update the national deployment and vaccination plans; support to integration of vaccination database with other health information systems; and a communication campaign to provide information to climate-vulnerable populations on vaccine delivery and contingency plans in case of extreme weather.

**82.** **Climate change mitigation co-benefits will be generated under the project through** : (i) support for effective health
care waste management, such as use of non-burn technologies; and (ii) support for the development of micro-plans that promote the use of high energy efficiency or hybrid energy consumption.

**83.** The project will support the procurement and deployment of approximately 170 integrated sterilization-shredding
machines in the amount of US$24 million to provide for instant and safe disposal of medical waste arising from the COVID-19 vaccine deployment. The machines can shred and disinfect medicine bottles, tubes, blister packs, catheters, syringes, glucose bottles, blood bags, ampoule bottles, and used needles. Utilizing only water and electricity, the machines using newer technology do not require any chemicals to operate and produce shredded disinfected waste that can be disposed of through regular municipal waste channels. The machines do not produce any emissions and provide a safer alternative for operators and the surrounding environment through minimizing human interference and/or contact with raw medical waste or the final by product. Further, owing to the slow and minimal nature of its internal mechanical parts, the machines provide anywhere from 20 to 40 percent less consumption in electricity. In addition, the average life span of the machines is 12-15 full years of operational functionality. This comes in contrast to the regular separate autoclave and shredder machines, which have 8-10 years of productive service, on average.
Finally, the introduction of such machines will minimize the environmental, medical, and social hazards associated with the process of collection, storage, transportation, and disposal through regular incineration process of medical waste management.

**G.** **Citizen Engagement**

**84.** A key part of the COVID-19 vaccination campaign is the community engagement and outreach element of the
overall framework and implementation plan put in place by the GOI to tackle the pandemic during its various stages.
The engagement of communities is critical to build community knowledge and confidence, establish trust, ensure governments respond to community needs (including vulnerable groups), and is thus a critical component of the COVID-19 response. The GOI recognizes the importance of citizen engagement in the COVID-19 vaccination campaign.
This is clearly demonstrated in the Demand Generation and Community Engagement Plan for COVID-19 Vaccines in Iraq developed under I3RF, which seeks to: (i) effectively communicate with the Iraqi population about COVID-19 vaccination to ensure vaccine acceptance and encourage uptake; and (ii) empower communities in feedback and accountability measures to improve decision making and service delivery related to vaccination.

Page 32 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**85.** To support the equitable implementation of subcomponent 1.2 on Support for Deployment of COVID-19 Vaccines
and Component 2 on Project Management and M&E, the project will support the implementation of the Demand General and Community Engagement Plan through the development of:

- communication strategies, mass campaigns and information, education and awareness building to disseminate
official information to communities and sensitize citizens of the risks related to COVID-19, supported by tailored awareness raising on preventative actions and the GOI’s COVID-19 response;

- participatory platforms to engage communities in assessing needs and prioritizing solutions and ensure
community members, vulnerable groups (elderly, disabled, large households), and community-based organizations are able to articulate local needs (for immediate emergency needs or for reestablishing livelihoods).

- a participatory monitoring and reporting mechanism to enable communities to help monitor the COVID-19
response at the local level. At the outset this might include identification of gaps at the point of service delivery (information availability, access to testing, access to relevant care, equal treatment etc.) to ensure inclusivity and identify improvements for GRM.

**86.** While these processes ensure that communities can provide informed feedback and play a role in local monitoring,
the challenge of implementation lies in social distancing policies. To ensure that communities can engage nevertheless, the project will actively engage with citizens to collect feedback on project performance, including through the use of the Iterative Beneficiary Monitoring (IBM) survey and social media surveys. Findings from such surveys will be used to improve the communication campaign and citizen engagement. Through the IBM, as well as social media surveys, engagement with community and religious leaders, especially in remote areas, will ensure the inclusion of their ongoing feedback in the rollout and implementation of the COVID-19 vaccination campaign to strengthen targeting accuracy and increase uptake. To ensure citizen engagement, the project will: (a) ensure community engagement teams are gender-balanced; (b) target messages to areas where vulnerable groups, including refugees and IDPs, reside to inform them about safety measures and benefits; (c) tailor messages to the elderly and those with medical risks including their target family members and health care providers; and (d) provide information for disabled people in accessible formats, like Braille, large print; text captioning; videos etc. The project will also explore the possibility of including NGO representation in oversight bodies established to oversee transparent and inclusive administration of vaccines.

**H.** **Gender**

**87.** Gender inequities and norms influence access to critical health services, as well as risk of exposure to disease,
particularly in emergency situations and pandemics. Factors that constrain access to and use of health services by women in Iraq include limited mobility and financial capacity, competing demands of paid and unpaid work, and limited access to information. [10] The reported incidence of COVID-19 is higher among men than women – 59 percent of registered COVID-19 cases in Iraq to date were among men. Moreover, women have also been impacted by the discontinuity of essential RMNCAH-N services, including for maternal and sexual and reproductive health, and GBV. [11] The GBV Information Management System (GBVIMS) has recorded a marked rise in the number of reported incidents of violence in 2020. [12] 10 UN Women (2018), Gender Profile- Iraq, A situation analysis on gender equality and women empowerment in Iraq.
11 UN Women (2020). Report on the Impact of COVID-19 on Women.
12 Gender Based Violence Information Management System Annual Narrative Report. January – December 2020.
https://iraq.unfpa.org/sites/default/files/resource-pdf/gbvims_narrative_report_of_2020.pdf Page 33 of 54

Iterative Beneficiary Monitoring (IBM) survey


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**88.** COVID-19 vaccine uptake is lower among women in Iraq. According to the findings of the Facebook survey
conducted under I3RF, only 25 percent of female respondents indicated they would get vaccinated when the COVID19 vaccine is made available compared to 40 percent of male respondents. Actual vaccination coverage shows more stark gender differences in uptake, with men receiving approximately 65 percent of vaccines delivered to date. [13] Until recently, nursing mothers and pregnant women were not eligible to receive COVID-19 vaccines. This can also partly explain the lower vaccination rates among women.

**89.** Lack of understanding of the benefits and importance of the vaccine could have serious repercussions in the uptake
among priority population groups, especially women who have more limited options to access information than men.
For example, 67 percent of women in Iraq use the Internet compared to 84 percent of men. These gender dimensions intersect with other inequities, particularly for populations that are poor, with limited access to formal education, living in hard-to-reach areas, temporary or informal settlements, or living with disabilities.

**90.** Specific considerations in terms of media tools and messaging will be made when targeting women, men, and
vulnerable populations in rural areas who are much more likely to have limited access to information. The project aims to do this by training female workers in community-based organizations and women-led NGOs to help with the dissemination of vaccine information and ensure that the targeted messaging will resonate and lead to vaccination awareness and uptake among women and men. The communication plan will ensure registration/vaccination sites be made accessible to women by taking into account timing and locations convenient for them and that female workers will be available at sites to answer questions. Additional details will be included in the POM. All data collection, monitoring, and analysis will be done in a sex-disaggregated way to the extent possible.

**91.** The project components also address gender dimensions with targeted interventions including: (i) positive
discrimination in vaccine registration and targeting activities to increase the proportion of women receiving the vaccine to discontinue the trend of male preferencing; (ii) integration of gender-responsive approaches in communication strategies with the public, including use of multiple accessible mediums in local languages; (iii) use of targeted messaging, and the creation of responsive platforms for registry of inquiries and grievances through a variety of mediums to target women and different vulnerable groups; and (iv) support for promotion of awareness and use of gender-based violence services, including the expanded network of integrated services at health facilities that offer medical, legal, psychosocial support and referrals. These services are offered by health facility staff that received GBV counselling and messaging as part of their regular on-the-job training to support and direct vulnerable women to specific support channels and resources. MOHE, supported by UN agencies, developed a remote and face-to-face GBV counseling flowchart targeting primary health care workers to clarify management methods and referral pathways.
These service adaptations were informed by a rapid assessment of available health care options for survivors of GBV during the COVID-19 outbreak. The survey included health care workers from primary health care centers, hospitals, and mobile medical clinics from 16 districts in Iraq. Of those surveyed, 69 percent of health facilities reported that their staff have already been trained on GBV. Following the COVID-19 outbreak, 81 percent of health facilities surveyed have already updated their referral pathways. Among those health facilities, 95 percent included GBV services in their updates. These interventions will be monitored and measured through the project’s results framework, TPMA reports, and through ESF instruments.

13 Sex-disaggregated data by priority group on vaccination uptake is not available, however, the gender gap in uptake among these groups is likely to be similar to the overall trend. This project will contribute to collection of sex-disaggregated data across priority groups whenever possible.

Page 34 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**RESULT_FRAME_TBL_PDO**

**Indicator Name** **PBC Baseline** **Intermediate Targets** **End Target**

**1** **2** **3** **4** **5** **6**

through project financing (Number)

**PDO Table SPACE**

**Intermediate Results Indicators by Components**

**RESULT_FRAME_TBL_IO**

**Indicator Name** **PBC Baseline** **Intermediate Targets** **End Target**

**1** **2** **3** **4** **5** **6**

**COVID-19 Vaccines and Deployment**

Percentage of administered doses which are captured in the national vaccination digital registry (Percentage) Percentage of vaccination sites which publicized detailed performance data on a regular basis in the last quarter (Percentage) Percentage of vaccination sites with functional cold chain (Percentage) Percentage of reported serious AEFI cases for which investigations were initiated within 48 hours (Percentage) 0.00 25.00 40.00 55.00 79.00 85.00 95.00 95.00 0.00 50.00 70.00 80.00 90.00 90.00 90.00 90.00 0.00 50.00 90.00 100.00 100.00 100.00 100.00 100.00 0.00 20.00 50.00 80.00 80.00 80.00 80.00 80.00 Number of health 0.00 200.00 400.00 600.00 800.00 1,000.00 1,000.00 1,000.00 Page 40 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**RESULT_FRAME_TBL_IO**

**Indicator Name** **PBC Baseline** **Intermediate Targets** **End Target**

**1** **2** **3** **4** **5** **6**

workers who received training in vaccination with GBV-related content (Number) Number of communication initiatives supported by the project to address vaccine hesitancy (Number) 0.00 1.00 2.00 3.00 4.00 5.00 5.00 5.00

**Project Management and Monitoring and Evaluation**

Percentage of feedback cases registered in the project's grievance redress mechanism (GRM) in the last quarter addressed within a timeframe specified and publicly communicated by the project (Percentage) Percentage of vaccination sites visited by the project TPMA in the last quarter (Percentage) Number of public discussion meetings conducted on the results of the TPMA (Number)

**IO Table SPACE**

0.00 10.00 40.00 60.00 80.00 90.00 95.00 95.00 0.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 0.00 1.00 2.00 3.00 4.00 4.00 4.00 4.00 Page 41 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**UL Table SPACE**

**Monitoring & Evaluation Plan: PDO Indicators**

**Methodology for Data**
**Indicator Name** **Definition/Description** **Frequency** **Datasource**
**Collection**

**Responsibility for Data**
**Collection**

PMU/MOHE PMU/MOHE MOHE/TPMA Administrative data Administrative data Survey by TPMA Percentage of specific priority populations fully vaccinated Percentage of fully vaccinated priority groups who are female Number of project-supported COVID-19 vaccinations sites with adequate health care waste management for vaccination The indicator will track the number of the eligible people as defined being among a specific set of priority groups in the National Deployment and Vaccination Plan (NVDP)/government prioritization list who are fully vaccinated from COVID-19 using vaccines that meet Bank's vaccine approval criteria.

The denominator is the number of people who were in the target groups and were fully vaccinated with 2 doses, and the numerator will be the number of women vaccinated with 2 doses in the target groups.

The project will invest in providing adequate waste management equipment at the facility level.
Monitoring of the 3 months 3 months 3 months NDVP, digital vaccination registry, national paper-based vaccination registry NDVP, digital vaccination registry, national paper-based vaccination registry TPMA reports Page 42 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038) continuous availability and adequate functionality of adequate wastemanagement processes as per established standards will be maintained throughout project implementation.

Number of COVID-19 vaccine doses acquired through project financing

**ME PDO Table SPACE**

This indicator will measure the number of COVID-19 vaccines that have been procured by the GOI through World Bank financing support.

3 months MOHE records Administrative data

**Monitoring & Evaluation Plan: Intermediate Results Indicators**

**Methodology for Data**
**Indicator Name** **Definition/Description** **Frequency** **Datasource**
**Collection**

PMU/MOHE

**Responsibility for Data**
**Collection**

PMU/MOHE PMU/MOHE Percentage of administered doses which are captured in the national vaccination digital registry Percentage of vaccination sites which publicized detailed performance data on a regular basis in the last quarter The indicator will track the percentage of administered COVID-19 vaccines which are captured in the national vaccination digital registry.

Percentage of vaccination sites which publicize detailed performance data 3 months 3 months Digital vaccination registry, vaccine logistics management information system National vaccination dashboard Administrative data Administrative data Page 43 of 54

vaccine logistics management information system


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038) on a regular basis in the last quarter 3 months 3 months Every 3 months Percentage of vaccination sites with functional cold chain Percentage of reported serious AEFI cases for which investigations were initiated within 48 hours Number of health workers who received training in vaccination with GBV-related The project will track the continuous functionality of the cold supply chain to ensure that vaccines are at all times - maintained at optimal condition until being administered to beneficiaries This indicator will measure the percentage of reported serious Adverse Events Following Immunization (AEFI) post COVID-19 vaccinations that have been reported to the Iraqi MOHE surveillance system, GRM and other channels that have been addressed and investigated within 48 hours of reporting to the total number of reported AEFIs. The aim is to measure the adequate and timely response and investigation to the reported AEFIs reported post COVID-19 vaccinations.

This indicator will measure the number of Healthcare MOHE and TPMA reports Iraq MOHE surveillance system, GRM data, MOHE incident reporting and media sources.

MOHE and TPM reports TPM Administrative and public data TPM MOHE/TPMA PMU/MOHE and TPMA MOHE/TPMA Page 44 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038) content workers who have received training on Gender Based Violence related content.
The training will address the dimensions of : identification of GBV victims, simple counselling and support mechanisms and possible referral pathways for further assessment and management of possible such cases.

Number of communication initiatives supported by the project to address vaccine hesitancy Percentage of feedback cases registered in the project's grievance redress mechanism (GRM) in the last quarter addressed within a timeframe specified and publicly communicated by the project This indicator will track the number of communication initiatives that are either conducted or/and substantially supported by MOHE for the public to address the issue of vaccine hesitancy.

The project will maintain a functioning grievance redress mechanism (GRM).
Grievances will be tracked and analyzed, and feedback will be provided to MOHE management for corrective actions, as needed. The project operations manual will include the specific process Every 3 months 3 months MOHE/TPMA MOHE GRM records Administrative data Administrative data MOHE/TPMA MOHE/TPMA Page 45 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038) to be followed.

Percentage of vaccination sites visited by the project TPMA in the last quarter Number of public discussion meetings conducted on the results of the TPMA

**ME IO Table SPACE**

~~.~~ This indicator will monitor the percentage of project supported facilities visited by the Third Party Monitoring Agency in each quarter of the project lifetime. This will be calculated by dividing the number of the visited facilities divided by the number of the total number of supported facilities.

The indicator will track the number of public meetings/consultations conducted by MOHE on the results of the project's TPMA reports to elicit citizen and public participation on the needed course correction measures.

3 months Every 3 months TPMA reports, PMU records meeting minutes, PMU documentatio n Administrative data Administrative data TPMA, PMU/MOHE PMU/MOHE Page 46 of 54


Input:
**The World Bank**
Iraq COVID-19 Vaccination Project (P177038)

**ANNEX 1: Status of Vaccines as of 09/15/2021**

**Vaccine** **Stringent Regulatory Authority**

**Emergency Use Approval**

**WHO PQ/EUL**

BNT162b2/COMIRNATY Tozinameran (INN) Pfizer BioNTech United Kingdom: December 2, 2020 Canada: December 9, 2020 United States of America: December 11, 2020 European Union: December 21, 2020 Switzerland: December 19, 2020 Australia: January 25, 2021 mRNA-1273 - Moderna USA: December 18, 2020 Canada: December 23, 2020 EU: January 6, 2021 Switzerland: January 12, 2021 UK: January 8, 2021 WHO Emergency Use Listing (EUL): December 31, 2020 WHO EUL: April 20, 2021 WHO EUL: February 15, 2021, for vaccines manufactured by SK Bio and Serum Institute of India WHO EUL: March 12, 2021 AZD1222 (also known as ChAdOx1_nCoV19/ commercialized as COVISHIELD in India) AstraZeneca/Oxford Ad26.COV2.S - Johnson & Johnson UK: December 30, 2020 EU: January 29, 2021 Australia: February 16, 2021 (overseas manufacturing); March 21 [, ] 2021 (for local manufacturing by CSL – Seqirus) Canada: February 26, 2021 USA: February 27, 2021 Canada: March 5, 2021 EU: March 11, 2021 Switzerland: March 22, 2021 UK: May 28, 2021 Australia: June 25, 2021 BBIBP-CorV - Sinopharm WHO EUL: May 7 [, ] 2021 for vaccines manufactured by Beijing Institute of Biological Products Co Ltd E-Town Vaccine Industry Base No. 6 &9 Bo’xing 2nd Road Economic-Technological Development Area Beijing, P.R. China CoronaVac - Sinovac WHO EUL: June 1 [, ] 2021 for vaccines manufactured by Sinovac Life Sciences Co., Ltd. No. 21, Tianfu Street, Daxing Biomedicine Industrial Base of Zhongguancun Science Park, Daxing District, Beijing, P.R. China Page 47 of 54


Input:
## **Executive
 Summary**

On
 9
 May,
 the
 leadership
 of
 the
 warring
 sides
 in
 South
 Sudan’s
 civil
 war
 signed
 another formal
 ceasefire
 agreement.
 Only
 time
 will
 tell
 whether
 the
 warring
 factions
 can
 gain
 the confidence
 of
 the
 people
 of
 South
 Sudan
 will
 honour
 the
 already
 tenuous
 ceasefire
 in
 the long-‐term.
 Even
 if
 the
 ceasefire
 holds,
 the
 severe
 impact
 and
 consequences
 of
 the
 present situation
 will
 require
 a
 larger
 humanitarian
 response
 and
 continued
 political
 engagement
 by the
 international
 community
 to
 avoid
 political
 paralysis
 within
 an
 active
 conflict.

The
 conflict
 has
 had,
 and
 continues
 to
 have,
 a
 devastating
 impact
 on
 the
 security
 and
 human rights
 of
 the
 civilian
 population
 of
 South
 Sudan,
 targeting,
 threatening
 and
 disempowering
 a significant
 portion
 of
 the
 population
 based
 on
 their
 political
 and/or
 ethnic
 identity,
 as
 well
 as their
 physical
 location,
 or
 gender.
 It
 has
 been
 described
 as
 a
 “crisis
 of
 protection”,
 and
 has dramatically
 increased
 food
 insecurity
 and
 vulnerability
 to
 famine
 across
 the
 country.
 By
 the end
 of
 2014,
 it
 is
 estimated
 that
 one
 in
 every
 two
 South
 Sudanese
 may
 be
 affected
 by
 the conflict
 and
 its
 consequences
 including
 through
 direct
 violence,
 illness
 and
 famine.

Reports
 documenting
 acts
 amounting
 to
 war
 crimes
 and
 crimes
 against
 humanity (committed
 by
 armed
 actors)
 during
 the
 violence
 over
 the
 last
 five
 months
 have
 been published
 by
 UN
 Mission
 in
 South
 Sudan
 (UNMISS)
 Human
 Rights
 Division,
 Amnesty International
 and
 Human
 Rights
 Watch,
 among
 others.
 To
 complement
 existing
 reports,
 the Protection
 Cluster
 in
 South
 Sudan
 in
 conjunction
 with
 its
 partners
 have
 produced
 an updated
 Protection
 Trends
 Analysis,
 outlining
 current
 trends
 and
 changes
 in
 the
 situation since
 the
 initial
 report
 released
 on
 January
 19. [2] The
 aim
 of
 this
 report
 is
 to
 provide
 an
 overview
 of
 the
 main
 protection
 risks
 in
 South
 Sudan, how
 protection
 threats
 have
 evolved
 since
 the
 outbreak
 of
 the
 conflict,
 and
 outline emerging
 and
 specific
 threats
 experienced
 by
 the
 civilian
 population.
 Physical
 security caused
 by
 violence
 remains
 the
 single
 largest
 protection
 threat
 in
 South
 Sudan.
 Deliberate targeting
 of
 the
 civilian
 populations,
 including
 specifically
 women
 and
 children,
 and widespread
 destruction
 of
 civilian
 infrastructure
 and
 property,
 such
 as
 markets,
 homes, health
 facilities
 and
 livelihoods,
 has
 had
 a
 devastating
 impact
 on
 the
 people
 of
 South
 Sudan.
Although
 these
 and
 others
 protection
 threats
 are
 described
 in
 this
 report
 as
 distinct,
 they remain
 fundamentally
 interlinked
 requiring
 a
 cohesive
 protection
 and
 assistance
 response that
 is
 sensitive
 to
 the
 broader
 context.

Since
 January
 2014,
 increasing
 attention
 has
 been
 paid
 to
 how
 the
 international
 community addresses
 protection
 issues
 and
 its
 impact
 on
 conflict
 dynamics.
 While
 there
 is
 willingness among
 humanitarian
 actors
 working
 in
 water,
 food
 security,
 or
 shelter
 to
 integrate protection
 concerns
 and
 do
 no
 harm
 approaches
 into
 their
 responses,
 the
 lack
 of
 financial and
 staffing
 support
 represents
 the
 single
 most
 significant
 constraint
 to
 ensuring
 that protection
 approaches
 are
 fully
 mainstreamed.

2
 Protection
 Cluster
 Trends
 Analysis,
 19
 January
 2014.

3


Input:
of
 the
 current
 crisis;
 and
 emerging
 threats
 arising
 from
 increased
 food/livelihoods
 insecurity.

#### **Deteriorating
 conflict
 dynamics
 and
 spreading
 violence**

During
 the
 week
 of
 violence
 which
 began
 on
 December
 15
 with
 clashes
 within
 Government security
 forces,
 leading
 to
 high
 profile
 arrests
 and
 purges
 within
 Government
 and
 its
 security organs,
 leading
 to
 violence
 targeting
 civilians,
 an
 estimated
 600
 people
 were
 killed.
 By
 the end
 of
 the
 week,
 armed
 violence
 had
 swept
 across
 parts
 of
 Central
 Equatoria,
 Jonglei,
 Upper Nile
 and
 Unity
 states,
 with
 mass
 defections
 from
 the
 GRSS
 armed
 forces,
 community mobilisation
 and
 ethnic
 targeting
 of
 the
 civilian
 population
 and
 massive
 brutality.

Since
 December
 2013,
 human
 rights
 organisations
 and
 protection
 actors [4] have
 documented widespread
 gross
 human
 rights
 violations
 such
 as
 the
 use,
 by
 various
 armed
 actors
 -‐
 whether Government,
 Opposition
 or
 affiliates-‐
 of
 torture,
 sexual
 violence
 including
 gang
 rape,
 extra judicial
 killings,
 razing
 of
 homes
 and
 markets,
 systematic
 looting
 and
 diversion
 of
 food
 and medical
 stocks,
 and
 targeting
 civilian
 populations
 and
 installations
 such
 as
 hospitals
 and churches. [5] Military
 engagement
 between
 Government
 and
 Opposition
 forces
 in
 towns
 and other
 areas
 on
 strategic
 routes
 has
 been
 accompanied
 by
 verifiable
 and
 unverified
 reports
 of atrocities
 against
 the
 civilian
 population.

Not
 only
 are
 civilians
 being
 targeted
 on
 the
 basis
 of
 their
 ethnicity
 but
 also
 because
 of
 their presumed
 affiliations
 with
 the
 “wrong
 side”
 of
 the
 conflict
 by
 virtue
 of
 their
 tribal
 affiliation, political
 beliefs,
 or
 choosing
 not
 to
 become
 a
 combatant.
 These
 tactics
 have
 been
 used
 to deliberately
 deprive
 and
 coerce
 populations
 for
 broader
 military
 and
 political
 objectives
 – restricting
 the
 means
 of
 subsistence
 and
 survival
 and
 causing
 acute
 suffering.
 Despite
 repeat signing
 of
 the
 Cessation
 of
 Hostilities
 (CoH)
 agreements,
 Government
 and
 Opposition
 forces (and
 their
 proxies)
 continue
 to
 wantonly
 target
 civilians
 and
 civilian
 property
 in
 plain
 sight
 of the
 international
 community.
 Under
 international
 law
 deliberate
 targeting
 of
 civilians constitutes
 a
 war
 crime
 and,
 if
 conducted
 systematically
 and
 on
 a
 large
 scale,
 could
 amount to
 crimes
 against
 humanity.

Although
 major
 armed
 hostilities
 have
 largely
 focused
 on
 strategic
 areas
 in
 Greater
 Upper Nile,
 the
 impact
 of
 the
 conflict
 is
 much
 more
 widely
 felt
 and
 risks
 spilling
 into
 areas
 that
 are erroneously
 deemed
 “stable”
 or
 “less
 affected”.
 Indicative
 of
 this
 are
 reports
 of
 sporadic violence
 in
 Warrap
 and
 Lakes
 States,
 mobilization
 of
 community
 and
 youth
 militias,
 forced recruitment
 and
 on-‐going
 army
 defections,
 with
 associated
 violence
 in
 Western
 Equatoria, Central
 Equatoria,
 Western
 and
 Northern
 Bahr-‐el
 Ghazal,
 Unity,
 Upper
 Nile
 and
 Jonglei States.

Fighting
 in
 and
 around
 areas
 hosting
 refugees
 from
 outside
 South
 Sudan
 in
 Upper
 Nile
 and Unity
 States
 is
 further
 exacerbating
 poor
 security
 conditions
 for
 refugees
 and
 complicating relations
 between
 refugee,
 IDP
 and
 host
 communities. [6] The
 breakdown
 of
 social
 and economic
 bonds
 that
 currently
 are
 seen
 to
 protect
 some
 communities
 from
 being
 dragged 4
 South
 Sudan
 Protection
 Cluster
 Trends
 paper,
 January
 2014;
 Human
 Rights
 Watch
 reporting
 see: 5
 See,
 e.g.,
 UNMISS
 Interim
 Report
 on
 Human
 Rights
 Abuses
 in
 South
 Sudan,
 21
 Feb
 2014;
 Protection
 Cluster Trends
 Analysis,
 19
 Jan
 2014,
 available
 at http://southsudanprotectioncluster.org;
 and
 MSF
 press
 statements Jan-‐Apr
 2014
 see
 http://www.msf.org.uk/country-‐region/south-‐sudan 6
 South
 Sudan
 Protection
 Cluster
 Trends
 paper,
 January
 2014 7


Input:
into
 a
 wider
 conflict
 could
 do
 more
 to
 entrench
 violent
 conflict
 (by
 hardening
 ethnic identities)
 than
 national
 level
 military
 hostilities.

The
 observed
 deterioration
 and
 spread
 of
 violence
 from
 one
 area
 to
 another
 is
 in
 part enabled
 by
 the
 widespread
 availability
 and
 prevalence
 of
 small
 arms.
 It
 is
 impossible
 to credibly
 estimate
 the
 extent
 of
 the
 flow
 and
 number
 of
 arms
 into
 and
 within
 the
 country, given
 South
 Sudan’s
 porous
 regional
 and
 internal
 borders.
 In
 2011,
 Small
 Arms
 Survey estimated
 that
 the
 existing
 security
 forces
 –
 South
 Sudan
 People’s
 Liberation
 Army
 (SPLA), South
 Sudan
 National
 Police
 Service
 (SSNPS),
 Wildlife
 and
 Fire
 Brigade,
 numbering
 300,000
 -‐ held
 317,000
 small
 arms
 and
 light
 weapons
 in
 their
 possession.
 Even
 this
 figure
 is
 widely recognized
 as
 not
 being
 reflective
 of
 the
 real
 level
 of
 arms
 available
 in
 the
 country.
Moreover,
 the
 admitted
 existence
 of
 “ghost
 soldiers”
 on
 the
 payroll
 of
 GRSS
 security
 forces make
 it
 difficult
 to
 assert
 exactly
 how
 many
 individuals
 make
 up
 the
 total
 number
 of
 formal or
 informal
 security
 services.
 It
 is
 also
 not
 accounting
 for
 the
 arms
 that
 civilians
 may
 hold for
 their
 own
 protection,
 which
 are
 used
 for
 opportunistic
 crimes
 and
 engaging
 in
 the current
 ethnic
 targeting.

Finally,
 the
 conflict
 in
 South
 Sudan
 is
 complicated
 by
 the
 involvement
 of
 regional
 armed actors
 such
 as
 the
 engagement
 of
 the
 Justice
 Equality
 Movement
 (JEM)
 in
 Unity
 State
 and presence
 of
 the
 Ugandan
 Peoples
 Defence
 Force
 (UPDF)
 deployed
 at
 the
 request
 of
 the President,
 with
 the
 stated
 intent
 to
 safeguard
 the
 sovereignty
 of
 South
 Sudan.
 Threats
 to
 oil installations
 and
 activities
 of
 members
 of
 the
 Sudan
 Revolutionary
 Front
 (SRF)
 could
 further embroil
 Sudan
 into
 the
 conflict
 at
 the
 border,
 which
 remains
 tenuous.
 Despite
 strong
 public statements
 by
 South
 Sudan’s
 President
 Kiir
 and
 Sudan’s
 President
 Omar
 al-‐Bashir
 to
 stand united,
 Khartoum’
 loyalties
 are
 unpredictable.
 A
 key
 sticking
 point
 for
 Sudan
 will
 remain Uganda’s
 engagement,
 and
 alliances
 between
 the
 SPLA
 and
 Sudanese
 armed
 groups,
 such
 as the
 SRF
 or
 other
 Darfuri
 groups,
 or
 the
 influence
 of
 military
 hardliners
 in
 President
 Kiir’s inner
 circle,
 including
 loyalists
 who
 were
 part
 of
 the
 Khartoum
 Government
 of
 National Unity
 (GNU).

The
 withdrawal
 of
 UPDF
 from
 South
 Sudan
 has
 been
 one
 of
 Riek
 Machar’s
 main preconditions
 during
 the
 Addis
 Ababa
 talks
 and
 could
 also
 be
 seen
 as
 an
 indicator
 of
 the Government’s
 commitment
 to
 a
 peaceful
 resolution
 to
 the
 conflict.
 What
 is
 clear
 is
 that
 both parties
 continue
 to
 employ
 military
 engagement,
 delaying
 tactics,
 and
 exchange
 accusations of
 mass
 atrocities
 committed
 by
 the
 other
 side
 to
 seek
 political
 leverage
 in
 Addis
 Ababa.
Finally,
 the
 influx
 of
 refugees
 into
 Kenya,
 Uganda,
 Ethiopia
 and
 Sudan
 presents
 serious human
 security
 challenges
 for
 these
 countries,
 especially
 if
 these
 numbers
 swell
 in anticipation
 of
 further
 conflict,
 violence
 and
 displacement.

In
 a
 country
 where
 prevalence
 of
 arms
 was
 already
 notoriously
 high,
 individuals
 and communities
 are
 resorting
 to
 armed
 violence,
 against
 an
 environment
 of
 impunity
 and
 lack of
 law
 enforcement
 capacity,
 constantly
 shifting
 frontlines
 in
 the
 armed
 conflict,
 affecting perceptions
 of
 security
 and
 self-‐help
 measures
 taken
 ensure
 the
 safety
 of
 families, livelihoods,
 land
 and
 cattle.
 The
 widespread
 availability
 and
 use
 of
 arms
 perpetuates
 the cycle
 of
 retaliation
 and
 generalized
 insecurity,
 as
 well
 as
 increasing
 incidents
 of opportunistic,
 violent
 criminality.
 Reports
 of
 the
 mobilization
 of
 informal
 militias
 also
 raise 8


Input:
percentage
 of
 the
 population
 in
 the
 most
 affected
 States
 of
 Upper
 Nile,
 Unity,
 Jonglei
 and Central
 Equitoria
 State.
 While
 reports
 cannot
 be
 confirmed,
 because
 of
 poor
 access
 and limited
 presence
 of
 humanitarian
 and
 human
 rights
 partners
 to
 large
 parts
 of
 South
 Sudan, the
 indications
 from
 existing
 reports
 are
 deeply
 concerning.

In
 repeated
 interviews
 conducted
 by
 Protection
 Cluster
 partners,
 civilians
 who
 have managed
 to
 flee
 have
 reported
 consistent
 patterns
 of
 violence
 levied
 against
 them
 by
 all armed
 groups,
 including
 Government,
 Opposition
 and
 opportunist
 perpetrators
 of
 violence.

Based
 on
 credible
 reports
 and
 direct
 observation
 of
 the
 ferocity
 of
 the
 violence
 in
 some
 of South
 Sudan’s
 major
 towns,
 the
 Protection
 Cluster
 remains
 concerned
 about
 alarming reports
 of
 violence
 in
 areas
 that
 are
 not
 visible
 due
 to
 a
 lack
 of
 presence
 on
 the
 ground.
Images
 from
 organisations
 such
 as
 the
 Satellite
 Sentinel
 project
 and
 UNITAR
 have
 shown extensive
 razing
 of
 villages
 and
 other
 properties
 through
 the
 use
 of
 satellite
 imagery,
 and survivor
 testimonies
 have
 reported
 the
 clear
 and
 deliberate
 targeting
 of
 civilians
 by
 armed groups.

With
 consistency,
 eyewitnesses
 have
 remarked
 on
 the
 significant
 shift
 in
 the
 nature
 of
 the conflict
 in
 contrast
 to
 previous
 periods
 of
 armed
 violence
 in
 South
 Sudan.
 In
 particular, targeting
 of
 women
 and
 children
 by
 armed
 groups,
 whether
 Government,
 Opposition
 or other
 armed
 groups,
 has
 been
 repeatedly
 highlighted.
 Survivors
 have
 described
 in
 detail how
 armed
 groups
 have
 sought
 out
 woman
 and
 children
 –
 subjecting
 them
 to
 rape
 and sexual
 assault,
 prior
 to
 their
 execution.
 The
 excruciating
 brutality
 of
 detail
 provided
 by traumatised
 survivors
 mirrors
 the
 concerns
 raised
 by
 senior
 human
 rights
 experts
 and
 UN figures
 on
 the
 shifting
 nature
 of
 the
 conflict
 in
 South
 Sudan.

The
 unseen
 must
 be
 brought
 to
 the
 forefront
 of
 the
 minds
 of
 the
 international
 community when
 assessing
 the
 trajectory
 of
 the
 conflict,
 examining
 the
 credibility
 of
 the
 any
 cessation of
 hostilities
 or
 ceasefire
 agreement
 and
 assessing
 the
 needs
 of
 highly
 vulnerable
 and conflict
 affected
 populations.
 Reports
 of
 violence
 targeting
 civilians,
 in
 addition
 to information
 gathered
 by
 UN
 OCHA
 on
 displacement
 patterns,
 including
 secondary
 and multiple
 displacement
 due
 to
 conflict,
 indicates
 that
 the
 conflict
 is
 increasingly
 spreading into
 other
 States
 and
 other
 pockets
 of
 the
 country
 and
 is
 to
 date
 entrenching
 along hardened
 ethnic
 lines,
 as
 well
 as
 leading
 to
 increased
 fracturing
 of
 sub-‐clan
 tensions.
 Local level
 disputes
 and
 issues
 that
 may
 not
 translate
 into
 the
 attention
 of
 the
 international community
 are
 indicators
 of
 local
 level
 conflict.

While
 these
 may
 not
 result
 in
 significant
 increases
 in
 affected
 populations
 -‐
 either
 through loss
 of
 life,
 displacement
 or
 loss
 of
 employment/livelihoods,
 it
 has
 a
 significant
 impact
 for individuals
 and
 families
 caught
 in
 areas
 outside
 the
 reach
 of
 protection
 and
 humanitarian partners,
 and
 points
 towards
 the
 longer-‐term
 trajectory
 of
 the
 conflict.
 The
 Protection Cluster
 cautions
 against
 any
 analysis
 which
 categorizes
 specific
 states
 in
 South
 Sudan
 as ‘Red’
 or
 ‘Green’,
 ‘more’
 or
 ‘less-‐affected’
 by
 violence
 and
 susceptibility
 to
 conflict
 or otherwise
 reduces
 the
 conflict
 to
 the
 Greater
 Upper
 Nile
 area.
 Without
 a
 coherent
 and 12


Input:
At
 the
 point
 of
 arrival
 in
 IDP
 settlements,
 particularly
 PoC
 areas,
 gender
 and
 sexual
 based violence
 have
 been
 repeatedly
 and
 regularly
 reported. [8] There
 have
 been
 issues
 around formal
 reporting,
 as
 many
 IDP
 women
 are
 reluctant
 to
 come
 forward
 and
 file
 any
 formal report.
 Some
 actors
 have
 voiced
 concern
 at
 the
 emphasis
 on
 ‘getting
 the
 numbers’
 and
 the persistent
 call
 for
 ‘evidence’
 of
 GBV,
 which
 has
 undermined
 the
 GBV
 response
 and
 hindered preventive
 action
 being
 taken.

While
 there
 is
 a
 need
 for
 data
 collection
 including
 use
 of
 GBVIMS,
 it
 should
 be
 in combination
 with
 other
 elements
 of
 a
 GBV
 prevention
 and
 response
 based
 on
 assessment
 of risks
 and
 evidences
 from
 other
 emergencies.
 There
 are
 many
 barriers
 to
 reporting
 and
 data collection.
 It
 should
 be
 noted
 that
 security
 is
 not
 guaranteed
 for
 victims/survivors
 in
 PoC areas
 where
 victims/survivors
 live
 in
 close
 proximity
 to
 the
 perpetrator/s.
 There
 is
 no
 one
 or system
 to
 keep
 the
 victim/survivor
 safe
 if
 it
 is
 discovered
 that
 she
 has
 reported
 the
 violence, and
 the
 perpetrator
 finds
 out.
 The
 emphasis
 should
 not
 only
 be
 on
 documenting
 cases,
 but rather
 on
 recognition
 that
 GBV
 will
 occur
 in
 conflict
 and
 emergency,
 and
 that
 it
 is
 an underreported
 crime,
 with
 actions
 taken
 to
 prevent
 incidents
 based
 on
 known
 threats
 and risk
 factors.

Women
 and
 girls
 have
 complained
 of
 sexual
 harassment
 and
 assault
 in
 and
 around
 latrine and
 wash
 facilities,
 as
 well
 as
 poorly
 lit
 areas
 in
 the
 PoC
 sites
 during
 night
 time,
 facing
 risk
 of assault
 when
 they
 go
 outside
 of
 the
 PoC
 sites
 for
 livelihood
 and
 firewood
 collection.
 Limited patrolling
 in
 some
 locations,
 lack
 of
 lighting,
 limited
 number
 of
 grinding
 machines
 to
 grind food,
 and
 lack
 of
 access
 to
 charcoal
 or
 firewood,
 has
 put
 women
 and
 girls
 safety
 at
 risk.
Reports
 of
 GBV
 while
 women
 are
 walking
 to
 get
 sorghum
 grounded,
 or
 to
 collect
 firewood, have
 continued.

Inadequate
 provision
 of
 patrolling
 in
 some
 locations
 and
 inadequate
 security
 measures remain
 of
 concern
 high
 levels
 of
 harassment
 and
 reported
 sexual
 harassment
 and
 violence by
 women
 using
 particular
 roads
 and
 exits
 from
 PoC
 areas.
 Lack
 of
 services,
 either
 due
 to resources,
 access
 or
 space
 acts
 as
 deterrence
 to
 persons
 affected
 by
 sexual
 violence reporting
 crimes,
 seeking
 follow
 up
 treatment
 and
 achieving
 legal
 remedy.

#### **Structural
 and
 institutional
 violence**

An
 overlooked
 element
 of
 the
 types
 of
 violence
 in
 the
 current
 conflict
 is
 structural-‐ individuals
 and
 institutions
 leveraging
 their
 position
 to
 deliberately
 control
 or
 target
 specific groups.
 Since
 the
 conflict
 began,
 control
 of
 airports
 and
 roads
 has
 been
 used
 to
 deny
 people the
 freedom
 to
 move
 within
 South
 Sudan
 or
 access
 asylum,
 with
 continued
 reports
 of people
 being
 denied
 the
 ability
 to
 move
 around
 or
 leave
 the
 country
 by
 air,
 harassment
 at airports
 and
 general
 intimidation.

The
 ability
 to
 control
 the
 movement
 of
 people,
 goods
 and
 money
 has
 been
 utilised
 by
 both the
 Government
 and
 Opposition
 forces
 to
 demonstrate
 and
 exercise
 territorial
 control.
Armed
 actors
 are
 reported
 to
 have
 confiscated
 equipment,
 prohibited
 the
 use
 of
 some assets
 such
 as
 satellite
 phones,
 placed
 levies
 and
 fines
 on
 movement
 of
 people
 and
 goods, 8
 Noting
 that
 this
 may
 appear
 a
 particularly
 acute
 problem
 in
 PoC
 areas
 simply
 because
 of
 population concentrations
 and
 consistent
 access
 of
 humanitarians
 to
 them.

14


Input:
among
 other
 interference
 and
 restrictions
 on
 movement.
 The
 withholding
 of
 civil
 service salaries
 is
 a
 concerning
 mechanism
 used
 to
 control
 populations.
 In
 February
 2014
 it
 was reported
 that
 Government
 officials
 were
 requiring
 people
 to
 come
 to
 State
 capitals
 to collect
 their
 salaries
 –
 requiring
 individuals
 to
 cross
 conflict
 lines
 and
 presenting
 themselves in
 a
 location
 that
 a
 person
 felt
 unsafe.
 Using
 payment
 as
 a
 way
 to
 coerce
 people
 out
 of
 areas or
 deprive
 groups
 or
 locations
 of
 resources
 demonstrates
 that
 physical
 violence
 is
 not
 the only
 leverage
 over
 vulnerable
 groups.
 Restrictions
 on
 the
 legal
 flow
 of
 money
 undermines the
 resilience
 of
 education,
 health
 and
 other
 essential
 services
 to
 the
 violence
 and
 also destabilizes
 the
 markets
 and
 other
 economies.

More
 direct
 examples
 of
 this
 form
 of
 institutional
 violence
 levied
 against
 civilian
 populations include
 incidents
 in
 Maban
 where
 Nuer
 civilians
 were
 given
 48
 hours
 to
 leave
 the
 county
 by local
 authorities
 in
 mid
 April.
 While
 high
 level
 Government
 authorities
 may
 not
 have explicitly
 sanctioned
 or
 authorized
 specific
 actions
 or
 attempts
 to
 push
 specific
 ethnic
 groups out
 of
 ‘mixed’
 areas,
 many
 such
 statements
 of
 actions
 have
 been
 observed
 with
 little
 or
 no consequences.
 Disarmament
 has
 also
 become
 a
 visible
 tactic,
 with
 authorities
 disarming and/or
 demobilising
 SPLA/SSNPS
 of
 specific
 ethnic
 groups.

In
 addition
 to
 these
 obvious
 issues,
 Protection
 Cluster
 partners
 have
 witnessed
 the
 trend
 of increased
 militarization
 of
 civil
 administration
 and
 civil
 dispute
 mechanisms
 across
 the county,
 in
 both
 rural
 and
 urban
 areas,
 whether
 Government
 or
 Opposition
 controlled,
 and
 in disputes
 involving
 host
 communities,
 IDPs
 and
 refugees.
 Civil
 disputes
 mechanisms
 with military
 interference
 or
 involvement
 reduce
 the
 likelihood
 that
 due
 process
 will
 be
 observed in
 dispute
 resolution
 and
 increase
 intimidation
 of
 one
 or
 both
 parties.
 The
 trend
 of militarizing
 civil
 posts
 and
 conflating
 civil
 and
 military
 state
 functions
 has
 been
 observed
 in many
 States
 across
 South
 Sudan,
 and
 has
 not
 been
 limited
 to
 only
 those
 states
 with
 high incidents
 of
 armed
 violence.

The
 Protection
 Cluster
 is
 additionally
 concerned
 that
 administrative
 authorities
 are
 using their
 powers
 to
 curtail
 independent
 monitoring
 and
 reporting
 of
 journalists
 and
 media outlets,
 by
 authorizing
 and
 conducting
 raids
 or
 closing
 print
 and
 broadcast
 media.
 The
 raids on
 the
 Citizen
 and
 Juba
 Monitor
 represents
 how
 administrative
 control
 is
 being
 used
 to
 curb the
 flow
 of
 information
 and
 freedom
 of
 speech
 in
 South
 Sudan.

#### **Hate
 speech**

Hate
 speech
 has
 reportedly
 started
 increasing,
 including
 among
 youth
 and
 children,
 in
 urban contexts
 of
 displacement.
 This
 includes
 increased
 graffiti
 and
 general
 language
 used
 in relation
 to
 the
 ‘other’
 ethnic
 groups.
 The
 incident
 in
 Bentiu
 where
 local
 radio
 was
 alleged
 to have
 used
 radio
 to
 transmit
 hate
 messaging
 and
 instructions
 is
 one
 example
 of
 the
 concern that
 local
 language
 media,
 which
 remains
 largely,
 unmonitored. [9] That
 being
 said,
 the language
 used
 in
 public
 statements
 by
 both
 Opposition
 and
 Government
 representatives
 to media,
 in
 public
 gatherings
 and
 other
 meetings
 continues
 to
 be
 worrying
 in
 both
 its
 hostility 9
 The
 Protection
 Cluster
 has
 recommended
 the
 monitoring
 of
 local
 language
 radio
 and
 other
 media
 in
 both
 South Sudan
 but
 also
 Diaspora.
 If
 these
 activities
 are
 being
 conducted
 in
 a
 structured
 manner,
 the
 Protection
 Cluster
 is unaware
 of
 these
 activities
 or
 their
 outcome.

15


Input:
For
 example,
 within
 the
 PoC
 the
 lack
 of
 space,
 and/or
 inadequate
 use
 of
 existing
 space
 have meant
 that
 the
 installation
 of
 grinding
 machines
 for
 sorghum
 is
 limited.
 Sorghum
 cannot
 be eaten
 in
 its
 unground
 form,
 so
 largely
 (primarily)
 women
 need
 to
 leave
 PoC
 areas
 in
 order
 to grind
 sorghum
 and
 collect
 firewood
 for
 cooking,
 placing
 them
 at
 higher
 risk
 of
 protection threats
 –
 including
 increased
 vulnerability
 to
 some
 form
 of
 violence
 (as
 noted
 above).

While
 not
 the
 case
 in
 all
 PoC
 sites,
 in
 many
 the
 lack
 of
 space
 means
 there
 is
 not
 enough room
 within
 many
 areas
 designated
 to
 humanitarians
 for
 adequate
 child
 friendly
 spaces, locations
 to
 host
 medical,
 counselling
 and
 psycho-‐social
 support
 services
 for
 victims
 and survivors,
 spaces
 for
 education
 and
 other
 forms
 of
 recreation,
 which
 should
 in
 regular circumstances
 would
 assist
 in
 providing
 space
 to
 de-‐escalate
 tensions
 within
 PoC
 areas.

The
 patterns
 of
 funding
 has
 also
 seen
 the
 money
 concentrate
 on
 PoC
 sites
 which
 can
 provide the
 appearances
 of
 there
 being
 more
 services
 available
 inside
 the
 PoC
 sites
 than
 outside
 of it.
 In
 Juba
 in
 particular,
 the
 need
 for
 a
 much
 stronger
 urban
 response
 is
 required.
 In
 the absence
 of
 a
 perceived
 legitimate
 Government
 providing
 for
 some
 affected
 communities, including
 new
 people
 arriving
 –
 some
 of
 who
 are
 being
 brought
 by
 the
 humanitarian community
 to
 receive
 medical
 assistance
 or
 to
 be
 reunified
 with
 family
 members
 or provided
 protective
 accompaniment
 for
 onward
 travel.
 National
 NGO’s
 and
 Community Based
 Organisations
 (CBOs)
 who
 can
 provide
 a
 safe
 and
 alternative
 option
 to
 Government services
 are
 over-‐stretched
 and
 receive
 very
 little
 funding.
 Access
 to
 referral
 pathways remains
 a
 pressing
 challenge
 given
 the
 conflict,
 which
 prevents
 access
 to
 already
 limited services,
 including
 medical
 services
 such
 as
 those
 found
 at
 the
 Juba
 Teaching
 Hospital.

As
 the
 conflict
 continues,
 humanitarians
 will
 continue
 to
 intersect
 with
 the
 conflict
 and therefore
 protection
 concerns
 –
 in
 order
 to
 assure
 both
 protective
 and
 conflict
 sensitive programming,
 adequate
 resources
 must
 be
 channelled
 to
 the
 appropriate
 humanitarian actors
 to
 ensure
 effective
 and
 sustainable
 programming,
 including
 through
 integrating protection
 impacts
 and
 mitigation
 measures
 into
 their
 analysis
 and
 programming.

## **Impunity
 for
 serious
 violations
 and
 abuses
 against
 civilians**

In
 January
 2014,
 the
 Protection
 Cluster
 in
 South
 Sudan
 along
 with
 other
 actors
 warned
 of the
 significant
 risk
 that
 the
 month-‐old
 conflict
 could
 become
 entrenched
 along
 ethnic
 lines, including
 increasing
 ethnically
 motivated
 targeting
 of
 civilian
 populations. [10] In
 recent
 weeks, there
 has
 been
 a
 sharp
 focus
 on
 the
 scale
 of
 violence,
 marked
 by
 increased
 brutality
 in Malakal,
 Bor
 and
 Bentiu,
 with
 hundreds
 of
 bodies
 on
 the
 streets,
 reports
 of
 executions
 of civilians
 and
 deliberate
 targeting
 of
 women
 and
 children.

The
 visit
 of
 the
 UN
 High
 Commissioner
 for
 Human
 Rights
 and
 the
 Special
 Advisor
 for
 the Prevention
 of
 Genocide,
 in
 addition
 to
 comments
 made
 by
 senior
 international
 figures
 such as
 US
 Secretary
 of
 State
 John
 Kerry
 and
 South
 Sudan
 UN
 Humanitarian
 Coordinator
 Toby Lanzer,
 underscore
 the
 mounting
 concern
 that
 without
 sustained
 political
 engagement
 to 10
 Protection
 Cluster
 Trends
 Analysis,
 19
 January
 2014.

23


Input:
support
 the
 humanitarian
 response
 and
 the
 response
 capacity
 of
 UNMISS,
 the
 people
 of South
 Sudan
 will
 remain
 at
 serious
 risk
 of
 armed
 violence,
 with
 increasing
 risks
 of
 genocide.

While
 there
 are
 undoubtedly
 millions
 of
 persons
 in
 South
 Sudan
 who
 do
 not
 harbour
 intent of
 genocide
 towards
 their
 neighbours
 or
 others,
 recognising
 the
 potential
 trajectory
 of
 the conflict
 and
 the
 parties
 to
 the
 conflict
 is
 the
 first
 step
 to
 developing
 a
 coherent
 political response
 to
 this
 crisis.
 All
 efforts
 should
 be
 made
 to
 support
 and
 protect
 the
 people
 of
 South Sudan
 from
 violence.
 Dangerous
 and
 ominous
 practices
 such
 as
 the
 use
 of
 local
 radio stations
 to
 escalate
 violence
 should
 put
 the
 international
 community
 on
 high
 alert.
 In addition
 to
 the
 increased
 use
 of
 hate
 speech,
 the
 Protection
 Cluster
 notes
 with
 alarm
 the rhetoric
 of
 senior
 officials
 from
 both
 the
 Government
 and
 Opposition
 indicating
 support
 for violence,
 callous
 indifference
 to
 the
 life
 and
 welfare
 of
 all
 citizens,
 as
 well
 as
 a
 noticeable increase
 in
 provocative
 graffiti
 and
 the
 radicalisation
 of
 South
 Sudan
 youth
 groups.

Throughout
 the
 conflict
 there
 continues
 to
 be
 credibly
 outlined
 allegations
 of
 gross
 human rights
 violations,
 war
 crimes
 and
 crimes
 against
 humanity,
 including
 violations
 of international
 humanitarian
 and
 human
 rights
 law
 and
 serious
 abuses
 against
 the
 civilian population.
 This
 includes
 indiscriminate
 attacks
 and
 targeted
 extra
 judicial
 killings
 of civilians,
 including
 along
 ethnic
 lines,
 enforced
 disappearances,
 gender-‐based
 violence
 such as
 rapes
 and
 gang
 rapes,
 and
 instances
 of
 ill
 treatment
 and
 torture
 by
 forces
 from
 both
 sides of
 the
 conflict,
 targeting
 foreigners
 or
 nationals
 of
 South
 Sudan. [11] In
 addition
 to
 the
 wilful targeting
 of
 civilians,
 including
 girls
 and
 boys,
 other
 serious
 violations
 of
 human
 rights
 and grave
 breaches
 of
 humanitarian
 law,
 including
 blatant
 disregard
 for
 the
 life
 and
 welfare
 of civilians,
 have
 been
 documented.
 This
 has
 included
 wanton
 destruction
 and
 occupation
 of civilian
 property,
 including
 hospitals,
 schools
 and
 markets;
 razing
 of
 villages;
 sexual
 and physical
 violence;
 recruitment
 of
 children
 into
 armed
 groups
 and
 armed
 forces,
 and deliberate
 separation
 of
 families;
 blocking
 access
 to
 humanitarian
 goods,
 services
 and
 places of
 safety;
 attacks
 on
 humanitarian
 and
 civilian
 objects,
 including
 UNMISS
 PoC
 sites;
 and, attacks
 against
 civilians
 just
 outside
 but
 in
 close
 proximity
 to
 the
 perimeter
 of
 UNMISS
 PoC Areas.

Reports
 of
 grave
 breaches,
 violations
 and
 serious
 abuses
 continue
 to
 arise
 in
 the
 context
 of on-‐going
 and
 recent
 fighting
 –
 with
 patients
 found
 with
 signs
 of
 being
 killed
 at
 close
 range
 in their
 hospital
 beds
 in
 Malakal
 during
 attacks
 in
 late
 February. [12] Among
 others,
 the International
 Crisis
 Group
 and
 Amnesty
 have
 documented
 on-‐going
 violence
 and
 abuses targeting
 civilians. [13] Although
 public
 reporting
 by
 UNMISS
 has
 highlighted
 some
 of
 the national
 accountability
 mechanisms,
 the
 results
 remain
 unclear.
 An
 absence
 of
 serious, credible
 and
 transparent
 accountability
 measures
 could
 itself
 be
 a
 trigger
 for
 continued violence.
 With
 numerous
 reports
 that
 war
 crimes
 and
 crimes
 against
 humanity
 have
 in
 fact been
 committed,
 questions
 now
 arise
 for
 the
 broader
 international
 community
 on
 its 11
 See,
 e.g.,
 UNMISS
 Interim
 Report
 on
 Human
 Rights
 Abuses
 in
 South
 Sudan,
 21
 Feb
 2014;
 Protection
 Cluster Trends
 Analysis,
 19
 Jan
 2014,
 available
 at http://southsudanprotectioncluster.org/ 12
 See,
 e.g.,
 MSF
 Report,
 23
 Feb
 2014,
 available
 at http://www.msf.org.uk/article/south-sudan-medical-careunder-fire 13
 See
 http://www.crisisgroup.org/en/regions/africa/horn-of-africa/south-sudan.aspx 24


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

|Col1|ABBREVIATIONS AND ACRONYMS|
|---|---|
|BFP|World Bank-facilitated Procurement|
|CAA|Autonomous Debt Management Fund of Cameroon_(Caisse Autonome_<br>_d’Amortissements)_|
|CAR|Central African Republic|
|CDC|Centers for Disease Control and Prevention|
|CEMAC|Central African Economic and Monetary Community|
|CERC|Contingent Emergency Response Components|
|COVID-19|Coronavirus Disease|
|CPF|Country Partnership Strategy|
|CTN-PBF|Performance Based-Financing Technical Unit_(Cellule Technique Nationale PBF)_|
|DA|Designated Account|
|DSSI|Debt Service Suspension Initiative|
|E&S|Environmental and Social|
|EID|Emerging Infectious Diseases|
|ESCP|Environmental and Social Commitment Plan|
|ESF|Environmental and Social Framework|
|ESMF|Environmental and Social Management Framework|
|ESMP|Environmental and Social Management Plan|
|ESS|Environmental and Social Standard|
|FM|Financial Management|
|FTCF|Fast Track COVID-19 Facility|
|GBV|Gender-based Violence|
|GDP|Gross Domestic Product|
|GEMS|Geo-enabling Method for Monitoring and Supervision|
|GHSI|Global Health Security Index|
|GoC|Government of Cameroon|
|GRM|Grievance Redress Mechanism|
|GRS|Grievance Redress Service|
|HEIS|Hands-on Expanded Implementation Support|
|HSPRP|Health System Performance Reinforcement Project|
|IBRD|International Bank for Reconstruction and Development|
|ICT|Information and Communication Technology|
|IDA|International Development Association|
|IDP|Internally Displaced Person|
|IFR|Interim Financial Report|
|IHR|International Health Regulations|
|IMF|International Monetary Fund|
|IMS|Incident Management System|


Input:
- How to optimize decentralization of COVID-19 testing through Point of Care (PoC) GeneXpert
diagnostics – Cameroon’s highly decentralized administrative and public health system is particularly
well positioned to roll out a large PoC COVID-19 diagnostic network based on GeneXpert. It is expected
that increasing capacity at the sub-national level will improve not only diagnostics but also optimize
and streamline the 4Ts approach (Testing, Tracking, Tracing, Treating);

- How to improve Non-Pharmaceutical Interventions (NPIs) implementation at the sub-national level
through a National Framework for decision making: Cameroon due to its geographical size and
decentralized administrative divisions will need to tailor sub-national NPIs packages according to the
epidemiological and health capacity local contexts. Such tailoring will be done through a framework
which establishes the triggers to loosen and tighten the NPI implementation at sub-national levels.
Cameroon’s experience and lessons learnt will therefore provide insightful information on how to
design and implement a sound framework to guide NPI implementation in a large country with
heterogeneous foci of COVID19 transmission such as Cameroon.

**II.** **CONTEXT AND RELEVANCE**

**A.** **Country Context**

7. **With a population estimated at over 25 million in 2018, Cameroon is a lower-middle-income**


Input:
**rural-urban disparities** . Cameroon reports the 14 [th] lowest life expectancy rate in the world, and the
burden of disease remains high and dominated by communicable diseases. HIV/AIDS, malaria and
tuberculosis represent about 23.7 percent of total morbidity and 25 percent of deaths. Noncommunicable diseases are emerging strongly because of changes in people’s lifestyle and eating habits,
especially those of people in urban areas. Potentially epidemic diseases (cholera, meningococcal
cerebrospinal meningitis, yellow fever, measles), worsen the morbidity and mortality of the population
from time to time. The upsurge of health emergencies is generally related to epidemics, traumas,
movements of populations, and floods. Cameroon is at very high risk of infectious disease outbreaks,
particularly those of animal origin (zoonotic diseases). In recent years, Cameroon has had numerous
disease outbreaks. These include leishmaniosis (2017), polio (2014, 2019), yellow fever (2013), measles
(2015, 2019), and cholera (2011, 2014, 2020). Despite Cameroon’s vulnerability to outbreaks, particularly
in the Far North, there has been minimal investment in strengthening communicable disease surveillance
and response systems.

16. **Cameroon** **ranked 115/195 on the Global Health Security Index (GHSI) with an overall score of 34.4** **[4]**

---
[4] Global Health Security Index, Building Collective Action and Accountability, October 2019.


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

Cameroon’s international health regulations (IHR) core capabilities, [5] revealed key weaknesses in
emergency preparedness and response planning, biosafety, linking public health and security authorities
communications with healthcare workers during a public health emergency, and infection control
practices and availability of equipment are very low.

17. **Cameroon’s public health authorities assessed its capacities to respond to COVID-19 in January**


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

related to the disease itself (such as case detection, contact tracing) and tracking of individual people in
any context). Particular caution also relates to any activities that require stringent policies on Personally
Identifiable Information (PII) or that might interfere with existing/planned tailored Health Management
Information Systems. The general approach for implementing the GEMS method sustainably entails a
capacity-building training to be delivered to representatives from the PIUs and Task Team. The CTN-PBF
has already benefited from a GEMS training delivered in September 2019 and has subsequently used the
GEMS method to geo-map more than 3,500 health facilities throughout the country and create a digital
database on those facilities. Thus, the PIU can directly leverage the GEMS platform, ICT access, and
existing skills for the COVID-19 response, while the World Bank’s GEMS team will offer technical support
to the PIU as needs arise.


Input:
**response to be provided against the pandemic COVID-19 health threat** . In so doing, the assessment was
carried out in accordance with the Directives and Policy for IPF, the World Bank Guidance on FM in World
Bank IPF Operations issued on February 28, 2017, the guiding principles in risk assessment issued in April
2020 and the various FM and disbursement measures for preparation of operations under COVID-19
[emergencies including the latest guidance on Streamlined Fiduciary Implementation Support Measures](https://worldbankgroup.sharepoint.com/sites/wbunits/opcs/Knowledge%20Base/Fiduciary%20Impl%20Spprt%20for%20Actve%20Ops%20affctd%20by%20COVID19.pdf)
[for Active World Bank-financed Operations given Travel limitations due to COVID-19 Pandemic. The recent](https://worldbankgroup.sharepoint.com/sites/wbunits/opcs/Knowledge%20Base/Fiduciary%20Impl%20Spprt%20for%20Actve%20Ops%20affctd%20by%20COVID19.pdf)
reviews of the agency’s FM arrangements concluded that some persistent weaknesses and uncertainties
in the internal control system pertaining mainly to the FM staffing and the internal audit performance
continue to undermine the sound implementation of the ongoing HSPRP. The FM performance was
therefore assessed as moderately unsatisfactory with a substantial risk rating as substantiated by last FM
supervision mission conducted in March 2020. The CTN-PBF is taking immediate corrective measures to
address these shortcomings by project effectiveness under close supervision/hands-on support from the

Page 24 of 56


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

Customized financial reporting format generated from the UN agencies’ accounting systems will be
submitted on a quarterly basis. Those reports should provide enough detail to explain the use of funds
and contain information such as purchased equipment and goods, with detail of quantity and value,
cumulative data, funds balance, disbursement plan, etc.). Based on the level of risk assessed during
implementation, the project team may consider requesting for more detailed financial reports submitted
more regularly by the UN agencies.


Input:
89. **GBV/SEA/SH Risks** : The project has been given a preliminary rating of substantial risk for GBV/SEA/SH,
based upon the country context and project-specific indicators. This risk rating is subject to validation
following project approval, and GBV/SEA/SH risks will be further assessed and addressed during the
implementation phase, which will include a review of the preliminary screening exercise and establishment
of the corresponding measures to prevent and mitigate identified risks. The preliminary risk rating is
presently supported by risk factors related to both country and project indicators. Despite the recognition
of the importance of gender equality in the constitution and national development strategies, the situation
of women and girls in Cameroon is alarming. The prevalence of physical and sexual violence committed by
a husband or partner is the highest in Sub Saharan Africa (SSA) at 51 percent. Similarly, rates of sexual
violence are higher than those in the SSA region at 29 percent. Acceptance of the use of violence by
husbands/partners is also quite high in Cameroon, particularly by women. According to the Demographic
Health Survey 2011, almost half of women (47 percent) reported that men are justified for beating their
wives, 38 percent of men share those views. The Cameroonian Penal Code related to GBV was revised in
2016, adding several progressive in favor of women’s rights (equal rights in divorce, reproductive rights, law
against child marriage or SH) but many types of GBV/SEA/SH have not been sufficiently addressed (marital
rape, domestic violence). Furthermore, significant challenges remain in dissemination, enforcement, and
service availability. Although the MoPH is named as the key provider of medical services for survivors of
GBV/SEA/SH in the National Strategy against GBV, MoPH has not mentioned those services or even the fact
that GBV/SEA/SH is a health problem in its Health Sector Strategy for 2016-2027 [13] . Additional risk factors
include project activities that are planned in areas with higher levels of poverty, in humanitarian settings,
and also in remote or rural areas, which may hinder accessibility and supervision of female workers and
beneficiaries. Furthermore, specific feedback from women and girls about GBV/SEA/SH risks related to this
project have not yet been solicited through community consultations in safe and enabling environments,
and the health care system in Cameroon is not known to have a national code of conduct in place to address
GBV/SEA/SH risks in the health sector. Early indications from other COVID-19-affected countries also
suggest that the COVID-19 emergency might further increase the likelihood of GBV/SEA/SH in Cameroon. [14]

---
[14] This includes domestic violence and violence perpetrated against health workers, especially nurses. At this end and in the context


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

**Intermediate Results Indicators by Components**

|Indicator Name|PBC|Baseline|End Target|
|---|---|---|---|
|**Component 1. Emergency COVID-19 Response**|**Component 1. Emergency COVID-19 Response**|**Component 1. Emergency COVID-19 Response**|**Component 1. Emergency COVID-19 Response**|
|Number of acute health care facilities beds with isolation
capacity (number) (Number)||500.00|3,000.00|
|Number of households provided with food and basic supplies
within quarantined populations (number) (Number)||0.00|10,000.00|
|**Component 2. Supporting National and Sub-national, Prevention and Preparedness**|**Component 2. Supporting National and Sub-national, Prevention and Preparedness**|**Component 2. Supporting National and Sub-national, Prevention and Preparedness**|**Component 2. Supporting National and Sub-national, Prevention and Preparedness**|
|Number of designated laboratories with COVID-19 diagnostic
equipment, test kits and reagents (number) (Number)||7.00|17.00|
|**Component 3. Community Engagement and Risk-Communication**|**Component 3. Community Engagement and Risk-Communication**|**Component 3. Community Engagement and Risk-Communication**|**Component 3. Community Engagement and Risk-Communication**|
|Number of households reached with tailored information (e.g
individuals and decision makers in different sectors – travel and
tourism, food and agriculture, health care workers and
businesses) (Number)||0.00|10,000.00|
|Percentage of grievances received and addressed through the
GRM sequential process (Percentage)||0.00|100.00|
|**Component 4. Implementation Management and Monitoring and Evaluation**|**Component 4. Implementation Management and Monitoring and Evaluation**|**Component 4. Implementation Management and Monitoring and Evaluation**|**Component 4. Implementation Management and Monitoring and Evaluation**|
|M&E system established to monitor COVID-19 preparedness and
response plan (Text) (Yes/No)
||No|Yes|


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

|Monitoring & Evaluation Plan: Intermediate Results Indicators|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|**Indicator Name **|**Definition/Description **|**Frequency **|**Datasource **|**Methodology for Data**
**Collection **|**Responsibility for Data**
**Collection **|
|Number of acute health care facilities
beds with isolation capacity (number)|Number of acute health
care facilities beds with
isolation capacity at COVID-
19 designated health
facilities|Quarterly
|Designated
COVID-19
Health
facilities
|Self-assessment
|MoPH
|
|Number of households provided with
food and basic supplies within
quarantined populations (number)|Number of households
provided with food and
basic supplies within
quarantined populations in
affected communes|Quarterly
|_Administrative_
_data_
|Self-assessment
|MoPH/ MINEPAT

|
|Number of designated laboratories with
COVID-19 diagnostic equipment, test kits
and reagents (number)|Number of designated
laboratories with COVID-19
diagnostic equipment, test
kits and reagents|Quarterly
|Designated
COVID-19
Laboratories
|Self-assessment
|MoPH
|
|Number of households reached with
tailored information (e.g individuals and
decision makers in different sectors –
travel and tourism, food and agriculture,
health care workers and businesses)|Number of households
reached with tailored
information regarding
COVID-19 mitigation
strategies including social
distancing measures|Quarterly
|_A_dministrative
data
|Self-assessment
|MoPH/ MINEPAT
|
|Percentage of grievances received and
addressed through the GRM sequential
process|Percentage of grievances
received and addressed
through the GRM
sequential process|Quarterly
|MoPH
|Self-assessment
|MoPH
|
|M&E system established to monitor
COVID-19 preparedness and response
plan (Text)
|Whether an M&E plan have
been established in country
to monitor COVID19
preparedness and response
plan (Yes/No)|

Quarterly
|MoPH
|Self-assessment
|MoPH
|


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

**ANNEX 3: Partners’ Contributions to COVID-19 Response in Cameroon (as of August 10, 2020)**

**In kind**

**contribution**

Cash
Cash

**Pledged/**

**Earmarked towards (specify activities)**

**Received**

Received
Received

**From (donor/partner)** **To (recipient)**

**Financial**

**contribution**

**(amount)**

**UK Department For**

**International Development**

**(DFID)**

**Global Partnership for**

**Education (GPE)**

**Office of US Foreign**

**Disaster Assistance (OFDA)**

UNICEF US$450,000
US$231,963

Health.
Health/ WASH.

UNICEF US$74,000 Cash Received Education.

UNESCO US$15,000,000 Cash Pledged Education- Distance learning.

UNICEF US$462,963 Cash Received WASH.

**Central Emergency**

**Response Fund (CERF)**

**Central Emergency** UNICEF US$118,532 Cash Received WASH, CP, Nutrition, Education, Health.

**Response Fund (CERF)**

UNESCO US$266,145 Providing access to quality education and psychosocial support to conflict
affected children in NW and SW regions of Cameroon – CERF.

**France Natcom** UNICEF US$103,427 Cash Received WASH and Communication.

UNICEF

UNESCO

US$118,532

US$266,145

**Education Cannot Wait** UNICEF US$500,000 Cash Received Education.

**The Bureau of Population,**

**Refugees, and Migration**

**(US BPRM)**

UNICEF US$685,185 Cash Received Emergency.

**UK Natcom** UNICEF US$400,000 Cash Received Education.

**UNICEF France National** UNICEF EUR 200,000 Cash Pending WASH.

**Committee**

**SSCAF** UNICEF US$1,000,000 Pending Health.

**Cocoa Foundation** UNICEF US$200,000 Cash Pending Health.

**France/ Agence Française** MoPH EUR Budget Received


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

**European in Cameroon** Government of
Cameroon

EUR 9,000,000 Budget
support

Awaiting
signatur
e

Discussion ongoing.

Supplies, training, support to national and local coordination

Discussions ongoing.
Possibly information and awareness-raising in region.

Fight against disinformation on COVID among the media in Cameroon's crisis
contexts.

Fight against disinformation for local radio stations.

WHO Cameroon EUR 1,000,000 Cash Awaiting
signatur
e

CSOs EUR 700,000 Cash Awaiting
signatur
e

UNESCO EUR 100,000 Cash Awaiting
signatur
e

Fondation
Hirondelle (CSO)

United Nations
Interregional
Crime and
Justice Research
Institute
(UNICRI),
Ministere des
Relations
Exterieures du
Cameroun
(MINREX)

EUR 500,000 Cash Awaiting
signatur
e

EUR 500,000 Cash Ongoing Training on safe and dignified burial for health personnel, decentralized local
authorities, firefighters, local authorities and those responsible for burial in
mosques.


Input:
**The World Bank**
Cameroon COVID-19 Preparedness and Response Project (P174108)

expertise
DGSN EUR 20,000 In kind Received Protection and disinfection equipment.
COMIFAC/BSB EUR 500,000 Cash/ Ongoing Communication, awareness-raising campaign.
Yamoussa technical

EUR 500,000 Cash/
technical
expertise

Ongoing Communication, awareness-raising campaign.

COMIFAC EUR 500,000 Cash/
technical
expertise

Ongoing Awareness-raising campaigns among indigenous populations.

WHO EUR 70,000 Cash Received Training and technical assistance-Logistic support.
FTNS/COMIFAC EUR 450,000 Cash Ongoing Awareness-raising campaigns among indigenous populations.
COMIFAC EUR 250,000 Cash Ongoing Awareness-raising campaigns.

**Italy (Italian Agency for** MoPH – EUR 250,000 Received Test and treatment of Covid-19 patients at Bafoussam Regional Hospital.

**Development Cooperation,** Bafoussam /Awarde

**AICS)** regional hospital d

MoPH –
Bafoussam
regional hospital

EUR 250,000 Received
/Awarde
d
procedur
e

EUR 63.281,60 Pledged/
Awarded
procedur
e

Test and treatment of Covid-19 patients at Bafoussam Regional Hospital.

MoPH –
Regional
hospitals of
Maroua,
Mokolo,
Kousseri,
Yagoua and
Touloum

Remote monitoring of patients.


Input:
**The World Bank**
Balochistan Human Capital Investment Project (P166308)

CURRENCY EQUIVALENTS

(Exchange Rate Effective April 30, 2020)

Currency Unit = Pakistani Rupee (PKR)

PKR 160.38 = US$1

US$1 = SDR 0.73185

FISCAL YEAR
July 1 – June 30

Regional Vice President: Hartwig Schafer

Country Director: Patchamuthu Illangovan

Regional Director: Lynne D. Sherburne‐Benz

Practice Manager: E. Gail Richardson

Task Team Leader(s): Yi‐Kyoung Lee, Juan Baron, Laura Di Giorgio


Input:
**The World Bank**
Balochistan Human Capital Investment Project (P166308)

ABBREVIATIONS AND ACRONYMS

|AGP|Auditor General of Pakistan|
|---|---|
|ASER|Annual State of Education Report|
|BAEC|Balochistan Assessment Examination Commission|
|BCR|Benefit‐Cost Ratio|
|BESP|Balochistan Education Sector Plan|
|BHU|Basic Health Unit|
|BISE|Board of Intermediate and Secondary Education|
|CBA|Cost‐Benefit Analysis|
|CE|Citizen Engagement|
|CoI|Conflict of Interest|
|COVID|Coronavirus Disease|
|CRI|Corporate Results Indicator|
|DA|Designated Account|
|DDO|Drawing and Disbursement Officer|
|DEA|District Education Authority|
|DHIS|District Health Information System|
|DOS|Directorate of Schools|
|DP|Development Partner|
|ECE|Early Childhood Education|
|EHCWMP|Environmental and Health Care Waste Management Plan|
|EMIS|Education Management Information System|
|EmONC|Emergency Obstetric and Newborn Care|
|EPI|Expanded Program on Immunization|
|ESMF|Environmental and Social Management Framework|
|FM|Financial Management|
|FMS|Financial Management Specialist|
|GBV|Gender‐based Violence|
|GDP|Gross Domestic Product|
|GoB|Government of Balochistan|
|GoP|Government of Pakistan|
|GPP|Governance and Policy Program|
|GRM|Grievance Redress Mechanism|
|GRS|Grievance Redress Service|
|HCI|Human Capital Index|
|HF|Health Facility|
|HIES|Household Integrated Economic Survey|
|HMIS|Health Management Information System|
|HRH|Human Resources for Health|

Annual State of Education Report
Household Integrated Economic Survey


Input:
**The World Bank**
Balochistan Human Capital Investment Project (P166308)

|IA|Implementing Agency|
|---|---|
|IMF|International Monetary Fund|
|IRR|Internal Rate of Return|
|IUFR|Interim Unaudited Financial Report|
|LEC|Local Education Council|
|LHW|Lady Health Worker|
|M&E|Monitoring and Evaluation|
|MNCH|Maternal, Newborn, and Child Health|
|MUC|Marginal Utility of Consumption|
|NIPS|National Institute of Population Studies|
|NPV|Net Present Value|
|OECD|Organisation for Economic Co‐operation and Development|
|PCC|Project Coordination Committee|
|PDHS|Pakistan Demographic and Health Survey|
|PDO|Project Development Objective|
|PHC|Primary Health Care|
|PITE|Provincial Institute for Teacher’s Education|
|PMU|Project Management Unit|
|PoR|Proof of Registration|
|PPHI|People's Primary Healthcare Initiative|
|PPSD|Project Procurement Strategy for Development|
|PSC|Project Steering Committee|
|PTSMC|Parent‐Teacher School Management Committee|
|RHC|Rural Health Center|
|RMNCHN|Reproductive, Maternal, Newborn, Child Health, and Nutrition|
|RMP|Repatriation and Management Policy for Afghan Refugees|
|RPF|Resettlement Policy Framework|
|RSW|Regional Sub‐window|
|SED|Secondary Education Department|
|SSAR|Solution Strategy for Afghan Refugees|
|STEP|Systematic Tracking of Exchanges in Procurement|
|TFR|Total Fertility Rate|
|UNHCR|United Nations High Commissioner for Refugees|
|VSL|Value of Statistical Life|
|WDI|World Development Indicator|
|WHO|World Health Organization|

Balochistan Human Capital Investment Project


Input:
**The World Bank**
Balochistan Human Capital Investment Project (P166308)

TABLE OF CONTENTS

**DATASHEET ............................................................................................................................. 1**

**I.** **STRATEGIC CONTEXT ........................................................................................................ 5**

A. Country Context ................................................................................................................................ 5

B. Sectoral and Institutional Context .................................................................................................... 7

C. Relevance to Higher Level Objectives ............................................................................................. 12

**II.** **PROJECT DESCRIPTION ................................................................................................... 13**

A. Project Development Objective ..................................................................................................... 13

B. Project Components ....................................................................................................................... 14

C. Project Beneficiaries ....................................................................................................................... 17

D. Results Chain .................................................................................................................................. 17

E. Rationale for Bank Involvement and Role of Partners ................................................................... 17

F. Lessons Learned and Reflected in the project Design .................................................................... 19

**III.** **IMPLEMENTATION ARRANGEMENTS .............................................................................. 20**

A. Institutional and Implementation Arrangements .......................................................................... 20

B. Results Monitoring and Evaluation Arrangements ......................................................................... 21

C. Sustainability ................................................................................................................................... 22

**IV.** **PROJECT APPRAISAL SUMMARY ..................................................................................... 22**

A. Technical, Economic, and Financial Analysis .................................................................................. 22

B. Fiduciary .......................................................................................................................................... 25

C. Safeguards ...................................................................................................................................... 26

D. Gender ............................................................................................................................................ 27

E. Climate Co‐benefits ......................................................................................................................... 28

**V.** **KEY RISKS ....................................................................................................................... 28**

**VI.** **RESULTS FRAMEWORK AND MONITORING ..................................................................... 31**

**ANNEX 1: Economic and Financial Analysis ..................................................................... 37**

**ANNEX 2: Implementation Arrangements and Support Plan ........................................... 43**


Input:
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Balochistan Human Capital Investment Project (P166308)

DATASHEET

|Country(ies)|Project Name|Col3|
|---|---|---|
|Pakistan|Balochistan Human Capital Investment Project|Balochistan Human Capital Investment Project|
|Project ID|Financing Instrument|Environmental Assessment Category|
|P166308|Investment Project<br>Financing|B‐Partial Assessment|

|Financing & Implementation Modalities|Col2|
|---|---|
|[  ] Multiphase Programmatic Approach (MPA)|[  ] Contingent Emergency Response Component  (CERC)|
|[  ] Series of Projects (SOP)|[  ] Fragile State(s)|
|[  ] Performance‐Based Conditions (PBCs)|[  ] Small State(s)|
|[  ] Financial Intermediaries (FI)|[✓] Fragile within a non‐fragile Country|
|[  ] Project‐Based Guarantee|[  ] Conflict|
|[  ] Deferred Drawdown|[✓] Responding to Natural or Man‐made Disaster|

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|Total Project Cost|36.00|
|---|---|
|**Total Financing**|36.00|
|**of which IBRD/IDA**|36.00|
|**Financing Gap**|0.00|

|World Bank Group Financing|Col2|
|---|---|
|International Development Association (IDA)|36.00|
|IDA Credit|21.00|
|IDA Grant|15.00<br>|

|Col1|Credit Amount|Grant Amount|Guarantee Amount|Total Amount|
|---|---|---|---|---|
|**Pakistan**|21.00|15.00|0.00|36.00|
|National PBA|6.00|0.00|0.00|6.00|
|Refugee|15.00|15.00|0.00|30.00|
|**Total **|**  21.00**|**  15.00**|**   0.00**|**  36.00**|

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Balochistan Human Capital Investment Project (P166308)

**I.** **STRATEGIC CONTEXT**

**A. Country Context**

1. **Pakistan is at a crossroads as it deals with the coronavirus disease (COVID‐19) pandemic** .
Periodic macroeconomic crises and a low human capital basis have constrained the country’s growth
prospects. Over the last two decades, economic growth in Pakistan has averaged at 4.4 percent a year,
below the South Asian annual average of 6.3 percent. [1] Low investment in human capital, slow progress of
structural reforms, low private investment, and slow export growth due to an overvalued currency, among
others, have hindered growth prospects. [2] The country was making good progress in stabilizing its
economy and implementing much needed structural reforms. However, the COVID‐19 pandemic will have
significant negative impacts on the economy. The closure of businesses and disruption to the supply
chains are significantly affecting the services and manufacturing sectors, which account for nearly 80
percent of total gross domestic product (GDP). The impact of the ongoing economic disruption is expected
to contract GDP by 1.3 percentage points in FY20.

2. **There was a consistent and significant decline in poverty in Pakistan over the 14 years from**

---
[1] World Bank estimate.
[2] World Bank. 2019. _Pakistan at 100: Shaping the Future_ . Washington, DC: World Bank.


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**2001 to 2015, during which the poverty headcount measured using the national poverty line fell from**

**64.3 percent to 24.3 percent.** [3] These gains are likely to be reversed due to the COVID‐19 pandemic and
its associated containment measures. The challenges of poverty reduction can be further affected by
climate change and disaster risk‐related vulnerabilities. [4] The economic contraction is expected to
contribute to a sizeable increase in poverty, reversing the trend of sustained poverty reduction observed
over the 14 years. Urban workers employed in the informal sector and daily wage workers employed in
the formal sector will bear the brunt of the slowdown. In rural areas, expected decline in off‐farm
employment opportunities is also likely to increase vulnerability to shocks of households relying on
agriculture. It is important that the government prioritizes investments to ensure poverty reduction and
human capital losses are quickly offset to bounce back strongly.

3. **Human capital accumulation is low and the impact of COVID‐19 pandemic puts at risk some of**

---
[3] World Bank. 2018. _From Poverty to Equity ‐ Pakistan at 100_ . Washington, DC: World Bank.
[4] Climate change is expected to exacerbate extreme weather events in Pakistan, thereby increasing the vulnerability of people,

poverty headcount measured using the national poverty line


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**the gains made in recent years.** According to the World Bank Human Capital Index (HCI), if no
improvements in health and education service delivery take place, a Pakistani child born today is expected
to be only 40 percent as productive as s/he could be by age 18. With a large share of births taking place
outside health facilities (33.8 percent) and low immunization rates (65.6 percent), children are deprived
of a strong start to life. High rates of malnutrition and low learning outcomes contribute to the low HCI:
37.6 percent of children under age five are stunted; and learning poverty is very high with 75 percent of
Pakistani children not being able to read and understand a short age‐appropriate text by age 10.

4. **Pakistan has adopted a holistic approach to human capital accumulation and protecting human**

**capital is at the core of the country’s response plan to address the COVID‐19 pandemic.** The Government


Input:
**The World Bank**
Balochistan Human Capital Investment Project (P166308)

of Pakistan (GoP) embarked on a set of reforms and interventions, including: (a) the launch of a national
poverty alleviation program ‘Ehsaas’; (b) expansion of quality primary health care (PHC) for improved
health, nutrition and population outcomes through a ‘life cycle’ approach; (c) a focus on learning in
primary education to decrease learning poverty by half in a decade; and (d) revision of legislation for
women’s empowerment and increased participation in the labor force. In order to respond to the COVID‐
19 pandemic, Pakistan has strengthened health service delivery and used safety nets to protect the
vulnerable. Ehsaas has been one of the main instruments to mitigate the COVID‐19 impact through its
cash assistance package. The World Bank is supporting the GoP in this agenda through preparing the
Pandemic Response Effectiveness in Pakistan project and repurposing eight ongoing projects to quickly
mobilize funding for urgently needed response and mitigation measures. The second phase of the COVID‐
19 response will focus on interventions to mitigate socio‐economic impacts and support for the medium‐
term reform agenda so that Pakistan can rebound stronger as the COVID‐19 crisis subsides. Earlier this
year, the Punjab Human Capital Investment project was approved by the World Bank and a similar project
is under preparation in Khyber Pakhtunkhwa.


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5. **Balochistan has been facing security challenges due in part to sharing borders with Afghanistan**

**and Iran and to tribal conflict.** These security challenges result in an uncertain investment environment
contributing to the untapped economic potential of Balochistan, largely based on natural resource
production (for example, natural gas, coal, and minerals). [5] As a consequence, Balochistan has experienced
a slower economic growth over the years compared to other provinces (1.4 percent in FY14/15, compared
to 7.0 percent in Khyber Pakhtunkhwa, 4.3 percent in Punjab, and 3.2 percent in Sindh over the same
period) [ 6] and high poverty rates, reaching 67.3 percent in the isolated district of Dera Bugti. [7]

6. **Pakistan has had a protracted refugee situation since the 1970s, hosting 5 million Afghans at its**

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[5] Asian Development Bank. 2005. _Balochistan Economic Report._
[7] World Bank. 2019. Data4Pakistan‐District Development Portal (accessed on August 28, 2019).


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**peak in the 1990s.** Currently, Pakistan is hosting 1.4 million Afghan refugees, of which nearly half are
women. Since 2006, the GoP has issued Proof of Registration (PoR) cards. These cards enable their
temporary stay in the country and are renewed periodically. While refugees initially lived in special
villages, since the 1990s, they have been relatively free to move out to urban areas and access social
services. They are mainly employed in the informal sector and recently have been allowed to open bank
accounts.

7. **Refugees in Pakistan access education and health services in the same way as other residents**


Input:
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Balochistan Human Capital Investment Project (P166308)

delivered by UNHCR through the Pakistan Post. This program tries to mirror the support to citizens under
the Ehsaas umbrella in order to minimize unequal distribution of support.

8. **Balochistan hosts around 325,000 registered Afghan refugees.** About 47 percent of them are
females, and more than half of them (53 percent) are less than 18 years of age. Districts with the highest
presence of registered refugees include Quetta, Pishin, Chagai, Loralai, Killa Saifullah, and Killa Abdullah
(table 1). More than half of the refugees in Balochistan live in urban Quetta (56 percent), whereas the
remaining live in rural settlements (29 percent) and refugee villages (15 percent).

**Table 1. Number and Percentage of Afghan Refugees by District in Balochistan**

|District|Population|Number of Registered Afghan
Refugees|Percentage of Registered
Afghan Refugees|
|---|---|---|---|
|Quetta|2,275,699|187,031|8.2|
|Pishin|736,481|54,691|7.4|
|Chagai|226,008|28,901|12.8|
|Loralai|397,400|18,894|4.8|
|Killa Saifullah|342,814|18,842|5.5|
|Killa Abdullah|757,578|10,775|1.4|

_Source_ : Population data from Census 2017; Registered refugee data from UNHCR as of December 31, 2019.

_Note_ : The table includes data for districts with more than 10,000 registered refugees.

**B. Sectoral and Institutional Context**

9. **Pakistan has invested significantly in designing refugee protection framework and**


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**administrative practices that are consistent with international standards and norms.** Pakistan’s
Protection Framework for Afghan Refugees has developed over time. It includes: (a) implementing
administrative and legal measures for refugees, such as the exemption from applicability of the 1946
Foreigners’ Act; (b) authorizing Afghan refugees to work in the country; (c) issuing and renewing PoR cards
with the support of the UNHCR; (d) signing of the regional Solutions Strategy for Afghan Refugees (SSAR)
in 2012, with Iran and Afghanistan, under UNHCR facilitation; and (e) approving the Repatriation and
Management Policy for Afghan Refugees (RMP) in 2017. This Protection Framework has been found to
be adequate by the UNHCR and the World Bank.


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10. **Pakistan’s refugee management approach draws from the principles of the SSAR.** It has three
pillars: (a) support voluntary repatriation, (b) promote sustainable reintegration in Afghanistan, and (c)
provide continued assistance to host communities. The SSAR has five outcomes: (a) support to voluntary
repatriation, (b) access to shelter and essential social services for refugees, returnees, and host
communities, (c) improved and diversified livelihood opportunities through training and enhanced food
security, (d) social and environmental protection of refugees and returnees, as well as assistance and
support to host communities, and (e) capacity development of national authorities, associations,
organizations, and communities engaged with refugees, returnees, and host communities.

11. **The RMP builds on the SSAR and guides Pakistan’s efforts to safeguard refugees and maintain**

**protection standards that align with international norms and practices.** The RMP includes (a) continued
and gradual voluntary repatriation with assistance of the UNHCR, (b) documentation of undocumented
Afghan citizens, (c) introduction of visa policy for Afghan refugees, (d) regulated border management, and
(e) national refugee law.

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12. **Human capital in Balochistan is low due to the underlying sociocultural, economic, and**

**development challenges.** First, multiple sociocultural and economic barriers, such as low education levels,
high poverty rates, and traditional sociocultural norms, negatively affect utilization and outcomes in
health and education (table 2). The lack of awareness about the benefits of utilizing quality health and
education services, along with safety concerns, especially for females who are not allowed to travel alone,
results in low utilization of essential services that are critical to achieving better human development
outcomes. [8] Second, the settlement of a large share of dispersed households in a vast province makes
service delivery in remote areas challenging, leaving the most vulnerable population groups behind and
exacerbating inequalities **.** Third, despite the rapid transition to devolved public services, which led to an
increase in government allocation to health and education, weak institutional capacity coupled with
suboptimal governance has hindered the effective and efficient use of the resources to maximize the
development outcomes for children. [9] These challenges are likely further exacerbated by the COVID‐19
outbreak.


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**Table 2. Comparison of Key Health and Education Indicators in the Province of Balochistan and Pakistan**

|Health Indicatorsa|Balochistan|Col3|Pakistan|Col5|
|---|---|---|---|---|
|Infant mortality rate (per 1,000 live births)|66.0|66.0|62.0|62.0|
|Stunting rate (% of children under 5)|47.4|47.4|37.6|37.6|
|Skilled birth delivery (% of pregnant women)|38.2|38.2|69.3|69.3|
|Immunization, measles (% of children ages 12–23 months)|33.3|33.3|73.0|73.0|
|**Gender Gap: Enrollment and transition ratesb**|**Girls**|**Boys**|**Girls**|**Boys**|
|Net enrollment at the primary level (%)|35|56|71|83|
|Net enrollment at the secondary level (%)|13|20|35|43|
|Effective transition rate from primary to middle (%)|69|71|84|84|
|Effective transition rate from middle to high schools (%)|78|83|88|94|
|**Gender Gap: Students ages 5–16 yearsc**|**Girls**|**Boys**|**Girls**|**Boys**|
|Could read a grade 2 level story in Urdu (%)|20|31|43|47|
|Could read grade 2 level sentences in English (%)|15|26|36|44|
|Could do subtraction (%)|26|34|39|43|

_Source_ : a. PDHS 2017–18; b. Pakistan Education Statistics 2016–17; c. Annual State of Education Report (ASER)‐
National 2018.

13. **These cross‐cutting challenges along with sector specific supply‐side and demand‐side**

Pakistan Education Statistics 2016–17
Annual State of Education Report (ASER)


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**constraints have resulted in poor health indicators and large disparities by socioeconomic status.**
Balochistan performs worse than the national average across reproductive, maternal, newborn, child
health, and nutrition (RMNCHN) indicators. [10] Under‐five mortality rate is 78 per 1,000 live births in
Balochistan, compared to 74 per 1,000 live births at the national level. The total fertility rate (TFR) is 4.0
in Balochistan and 3.6 nationally, and almost half of the children under five are stunted in the province,
compared to about one in three at the national level. Differences in service utilization between the

8 Javed, S. A., M.D. Anjum, W. Imran, et al. 2013. “Correlates of Preferences for Home or Hospital Confinement in Pakistan:
Evidence from a National Survey.” _BMC ‐ Pregnancy and Childbirth_ 13:137.
ul Husnain, M.I., M. Rashid, and U. Shakoor. 2018. “Decision‐making for Birth Location among Women in Pakistan: Evidence
from National Survey.” _BMC Pregnancy and Childbirth_ 18:226. _https://doi.org/10.1186/s12884‐018‐1844‐8_ .
9 Alif Ailaan 2018. _2013‐2018 Five Years of Education Reforms in Balochistan. Wins, Losses and Challenges for 2018‐2023._
Islamabad: Alif Ailaan. vi‐33 pp.

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[10] NIPS and ICF (2019).


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**The World Bank**
Balochistan Human Capital Investment Project (P166308)

province and the national level are even more striking: 38 percent of deliveries are attended by a skilled
birth attendant (versus 69 percent nationally) and 56 percent of women receive at least one antenatal
care from a skilled provider (versus 86 percent nationally). The use of modern contraceptives is very low,
both at the provincial level (14 percent) and at the national level (25 percent), while the proportion of
children immunized against measles is an alarming 33 percent in the province versus 73 percent
nationally. Vulnerable populations present lower indicators: skilled birth deliveries are 93 percent in the
richest quintile and 22 percent in the poorest quintile, while the share of women receiving at least one
antenatal care from a skilled provider is 77 percent in urban areas versus 47 percent in rural areas. Among
the poorest quintile of Balochistan in FY12/13, 94 percent of deliveries were overseen by unskilled
attendants, similar to indicators among Afghan refugees in Pishin (94 percent). [11]

14. **Experience from other outbreaks shows that there is a high risk of health loss due to direct and**


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**The World Bank**
Balochistan Human Capital Investment Project (P166308)

another challenge for service delivery, especially institutional deliveries. Community midwives could
conduct normal deliveries in home birthing stations outside open hours of HFs, but many of them do not
have adequate hands‐on training. In addition, referral systems between communities and PHCs and
between PHCs and higher‐level HFs are further affected by the lack of transport systems and patient
prioritization.

16. **Suboptimal stewardship, limited use of evidence‐based practices,** **and fragmented health**