The World Bank Stunting Prevention and Reduction Project (P164845) REPORT NO.: RES42974 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF STUNTING PREVENTION AND REDUCTION PROJECT APPROVED ON FEBRUARY 28, 2018 TO THE REPUBLIC OF RWANDA February 20, 2022 Health, Nutrition and Population Global Practice Eastern and Southern Africa Region Regional Vice President: Hafez M. H. Ghanem Country Director: Keith E. Hansen Regional Director: Amit Dar Practice Manager/Manager: Francisca Ayodeji Akala Task Team Leader: Nkosinathi Vusizihlobo Mbuya The World Bank Stunting Prevention and Reduction Project (P164845) ABBREVIATIONS AND ACRONYMS AF Additional Financing CERC Contingent Emergency Response Component COVID-19 Coronavirus Disease 2019 CHW Community Health Worker DPEM District Plans to Eliminate Malnutrition ECD Early Childhood Development EVD Ebola Virus Disease FBF Fortified Blended Food HC Health Centre IDA International Development Association M&E Monitoring and Evaluation MDTF Multi-Donor Trust Fund NCDA National Child Development Agency PDO Project Development Objective PoE Points of Entry PoN Power of Nutrition PPSD Project Procurement Strategy for Development RF Results Framework RBC Rwanda Biomedical Center SDR Special Drawing Rights SPIU Single Project Implementation Unit SPRP Stunting Prevention and Reduction Project WASH Water, Sanitation and Hygiene The World Bank Stunting Prevention and Reduction Project (P164845) BASIC DATA Product Information Project ID Financing Instrument P164845 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 28-Feb-2018 30-Apr-2023 Organizations Borrower Responsible Agency MINISTRY OF FINANCE AND ECONOMIC PLANNING Rwanda Biomedical Center Project Development Objective (PDO) Original PDO The proposed Project Development Objective (PDO) is to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-61870 28-Feb-2018 07-Mar-2018 05-Jun-2018 30-Apr-2023 25.00 20.63 3.98 TF-A6567 28-Feb-2018 07-Mar-2018 05-Jun-2018 30-Apr-2023 20.00 10.16 9.84 TF-A6783 29-Jan-2018 07-Mar-2018 05-Jun-2018 31-Dec-2021 10.00 10.00 0 The World Bank Stunting Prevention and Reduction Project (P164845) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Stunting Prevention and Reduction Project (P164845) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Project Status: 1. The objective of this Restructuring Paper is to seek Regional Vice President approval for the proposed Level 2 restructuring of the Stunting Prevention and Reduction Project (SPRP, Credit Number 61870-RW). This restructuring proposal is in response to a request from the Government of Rwanda requesting the World Bank to initiate the restructuring to reallocate US$2.5 million from the Power of Nutrition Grant (Multi-Donor trust fund (MDTF) Grant Number A6567) to a Fortified Blended Food (FBF) subcomponent and reallocating US$2.7 million from the International Development Association (IDA) Credit to cover expenses incurred during government’s response to the Ebola crisis. This would be the second restructuring of the project. The SPRP was approved on February 28, 2018 and became effective on June 5, 2018, with a closing date of April 30, 2023. The Project Development Objective (PDO) is “to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts”. The project components are: (i) Prevention of Stunting at Community and Household Level; (ii) High Impact Health and Nutrition Services; (iii) Monitoring and Evaluation and Project Management; the project continues to be well managed by the Rwanda Biomedical Center/Single Project Implementation Unit (RBC/SPIU) with six dedicated specialists overseeing implementation. 2. The SPRP continues to enjoy high-level political commitment and strong multisectoral coordination under the leadership of the National Child Development Agency (NCDA). The SPRP has been under implementation for over three years with steady progress towards the PDO and disbursements on track (roughly 75 percent of the US$55.0 million disbursed). Progress on implementation and towards achievement of the PDO, project management and overall safeguards are all rated as “satisfactory” and there are no outstanding audit and interim financing reports. At the request of the Government, the World Bank carried out a first restructuring in August 2019 to include support for the procurement and delivery of FBF, establishing a US$8.0 million sub-component. In September 2019, a Contingent Emergency Response Component (CERC) was activated to support the National Ebola Virus Disease (EVD) Preparedness and Response Plan and enhance the country’s readiness to respond to the risk of cross border transmission. 3. The results from the 2019-20 Demographic and Health Survey (the most recent available data) are generally encouraging but suggest a mixed picture, namely: (1) stunting declined from 37.9 percent in 2015 to 33.1 percent in 2020 which represents sound progress but with persistent disparities across wealth quintiles and a rise in stunting in infants under six months (from 10.5 to 16.2 percent); (ii) exclusive breastfeeding declined from 87.3 to 80.9 percent; (iii) minimally acceptable diet increased slightly from 18 to 22 percent; (iv) anemia in women of reproductive age dropped from 19 to 13percent; and (v) postnatal care rose substantially from 43 to 70 percent. It is also assessed that the PDO is still achievable, and remains highly relevant to the country, with the country’s objective that all districts are expected to reduce stunting to 19 percent among children under five years old by 2024, in line with 2018-2024 Health Sector Strategic Plan, still yet to be achieved. 4. The Government has also continued to make solid progress in the implementation of project activities, despite the ongoing Coronavirus Disease 2019 (COVID-19) pandemic and the consequent movement restrictions meant to curtail the spread of the virus resulting in some disruptions in the delivery and utilization of essential health and nutrition services. Notable achievements in Component 1 include: 10,977 Early Childhood Development (ECD) settings (including home-based, community-based and center-based ECD) currently functional in 13 districts covered by SPRP, and 25,932 community health workers (CHWs) from these districts trained on integration of ECD services into routine community health package provision and on reporting of key ECD indicators; as of end of December 2021, 1 billion Rwandan Francs has been transferred to the 13 Project districts to support various activities in approved District Plans to Eliminate Malnutrition, such as procurement of foodstuff to support ECD centers, conducting supportive supervision to health facilities and communities, conducting quarterly District Plans to Eliminate Malnutrition (DPEM) coordination meetings The World Bank Stunting Prevention and Reduction Project (P164845) at all levels, etc.; Provision of water, sanitation and hygiene (WASH) materials to 8,656 households (materials such as water filters, plastic toilet slabs, iron sheets and doors for improved toilet structures). In addition, 15,967 households have received handwashing stations and 2,344 households provided with tanks for water collection. For Component 2: facility based performance based financing has been a success, with over 3 billion Rwandan Francs having been disbursed since 2019; the child scorecard, a tool to track the convergence of interventions and to strengthen the collaborative actions between service providers and service users, has been scaled up in all 19 districts (starting with SPRP districts, plus an additional six non-SPRP districts), 43,710 users including health care providers, Socio-Economic Development Officers at cell level, village leaders and community health workers were trained on utilization of the child scorecard and 675,216 child scorecard and dashboards tools were printed and distributed to districts. Under Component 3 the Project continues to be well managed by the Rwanda Biomedical Center/ Single Project Implementation Unit (RBC/SPIU) with six dedicated specialists overseeing implementation and coordination; the results of the Project baseline survey were widely disseminated by the government and the midline survey will be proceeding to the field by the end of February 2022. Procurement and Financial Management of the Project are both rated as “moderately satisfactory”. 5. The early results from the implementation of the FBF sub-component (of Component 1) are satisfactory. Enrollment has gradually improved with the FBF program now reaching more pregnant and lactating women as well as children aged 6-23 months from Ubudehe 1 and 2 categories. As a result of the additional support, the number of children on FBF increased from over 59,000 (August 2019) to over 104,000 (December 2020) while the number of pregnant and lactating women rose steeply from about 8,500 to over 53,000 during the same period. The expansion involved increased rations to existing targeted beneficiaries in Ubudehe 1 households, and inclusion of pregnant and lactating women from Ubudehe 2 households in the 13 target districts. When the COVID-19 pandemic struck in early 2020, the FBF program became an important part of the government’s response to the adverse economic impact of the pandemic, with authorities using their limited domestic resources to reach some of the most vulnerable households through existing social safety nets and in-kind programs such as FBF, ensuring access to nutritious foods for women and children. A recent qualitative study supported by the World Bank with communities in Rutsiro, Gakenke and Bugesera found that FBF is an important element of children’s diet (in terms of its nutritional value) and it is recognized by parents as such. FBF is not only supporting the nutrition of children 24 months and under, but also other children in the household when food is scarce. Reports of efforts by parents to collect FBF despite long distances and lack of transport highlights the important role it plays in supplementing food consumption for children. However, the enrollment rate has decreased in 2021 due to continuous stock-outs caused by insufficient funds. In fact, between December 2020 and May 2021, the provision of FBF declined by 17 percent for children aged 6-23 months and by 24 percent for pregnant and lactating women (in May 2021, 86,559 children and 40,817 women received FBF, down from 104,585 and 53,402 in December 2020, respectively). 6. The implementation of activities under CERC (Component 4) to support EVD Preparedness and Response Plan has been generally satisfactory. The CERC was activated at the height of the Ebola outbreak in neighboring Democratic Republic of Congo (DRC), shortly after the World Health Organization declared the outbreak a public health emergency of international concern in July 2019. At the time, Ebola cases were reported in some of the most populous provinces in DRC that share porous borders with Rwanda. With over 330 EVD cases and a 63 percent case fatality rate, there were major concerns with the high risk of cross border transmission, given frequent movements of people, and high levels of insecurity. The EVD CERC supported the Government’s comprehensive EVD preparedness plan, which focused on 15 priority districts. The June 2021 Implementation Report has indicated that 19 Points of Entry (PoE) were established and handed over to the ten targeted districts (Rusizi, Nyamasheke, Nyaruguru, Gisagara, Karongi, Rutsiro, Gicumbi, Nyagatare, Kirehe and Bugesera). Each PoE consists of three holding rooms and two toilets, water tanks with varying capacity (from 3m3 to 10m3), hand-washing facilities (varying between four to eight simultaneous users), public toilets (varying from four to six simultaneous users) and covered walkways. Moreover, construction works for the rehabilitation of eight isolation centers commenced in February 2021 and have since been completed. Two vehicles for The World Bank Stunting Prevention and Reduction Project (P164845) sample collection have been procured and are now operational, supporting the response to the current COVID-19 pandemic. Rationale for Restructuring: 7. The main rationale for the proposed restructuring is two-fold. First, to adjust the project objective and design in line with the activities implemented through the EVD-CERC activation. Second, to respond to the Government’s request of December 21, 2021 to reallocate Special Drawing Rights between disbursement categories to cover the expenses that have been incurred during the execution of activities in the EVD-CERC component under the IDA credit; and to reallocate another US$2.5 million from the Power of Nutrition (PoN) funded grant to a new FBF sub-component. The rationale for the continuation of the FBF activities remains sound. The pervasive levels of food insecurity amongst project beneficiaries persist and have also been exacerbated by the COVID-19 pandemic, running the risk of undermining progress on reducing stunting. Hence there is a need for continuity in the FBF program to address the nutritional needs of these vulnerable populations. 8. The main principles agreed on for the first restructuring in August 2019 remain valid for this restructuring. They are: (i) maintaining the integrity of the original design that was based on best buy interventions; (ii) protecting critical areas of the project that require catalytic external funding, such as reforming the country’s flagship CHW program, social behavior change communications activities, and the district-level multisectoral nutrition convergence agenda; and (iii) continued monitoring of the need for and impact of the FBF activities and making course corrections when needed. There are no outstanding audit and interim financing reports. The PDO remains achievable. 2. DESCRIPTION OF PROPOSED CHANGES 9. Changes in the PDO: With the CERC activation in September 2019, the PDO will be modified as follows: “to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts and provide immediate and effective response in the case of an eligible crisis or emergency”. 10. Change in the Project’s Results Framework (RF): CERC activation also requires corresponding updates to the project’s RF. To this end, the following two new indicators will be added to the RF, one at the PDO level, and the other at the Intermediate Results Indicator (IRI) level. These indicators are: (i) percentage of Ports of Entry which are operational (PDO level); and (ii) percentage of designated hospitals with isolation capacity (IRI). A detailed description of the changes made to the RF is provided in Section IV below. 11. Changes in Components and Costs: While the components remain the same, two changes are proposed in the allocation of project funds. First, reallocating US$2.5 million from Component1 2 (funded through the PoN Grant (MDTF A6567)) to a new FBF sub-component of Component 1 under the same grant, as agreed with the PoN to respond to the Government’s request of December 21, 2021. Second, reallocating a total of US$2,721,035 from Component 1 to Component 4 under the IDA credit, in response to the Government’s request of December 21, 2021. Table 1 below summarizes the revised project costs: 1 Terms “Project Component(s)” and “Project Part(s)” are used interchangeably (amendments to Legal Agreements use “Part”) The World Bank Stunting Prevention and Reduction Project (P164845) Table 1: Proposed Reallocation of Funds Across Components Component Original Cost Revised Cost at Revised Cost after (US$ million) CERC Completion of Activation (US$ CERC (US$ million) million) and Reallocation of PoN Grant 1-Prevention of Stunting 35.0 30.0 34.8 at Community and Household Levels 2-High-Impact Health and 14.5 14.5 12.0 Nutrition Services 3-Monitoring and 5.5 5.5 5.5 Evaluation and Program Management 4-CERC 0 5.0 2.7 Total 55.0 55.0 55.0 12. Reallocation between Disbursement Categories: To facilitate the reimbursement of expenditures (incurred from CERC activities) made in category 7 (EVD-CERC), the amounts of US$1.36 million (SDR 0.98 million), US$1 million (SDR 0.72 million) and US$0.36 million (SDR 0.25 million) have been reallocated respectively from Category 3, 2 and 1 to Category 7 (CERC); and an amount of US$2.5 million has been reallocated from Category 2 (Supply chain and staff training) to a new Category 5 (Goods-FBF) under the PoN grant. 13. Procurement. Following the completion of Project restructuring, the Project Procurement Strategy for Development (PPSD) will be updated by the government and submitted to the World Bank for review. II. SUMMARY OF CHANGES Changed Not Changed Project's Development Objectives ✔ Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ The World Bank Stunting Prevention and Reduction Project (P164845) PBCs ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_PDO_TABLE PROJECT DEVELOPMENT OBJECTIVE Current PDO The proposed Project Development Objective (PDO) is to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts. Proposed New PDO The proposed Project Development Objectives (PDO) are to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts and provide immediate and effective response in the case of an eligible crisis or emergency. The World Bank Stunting Prevention and Reduction Project (P164845) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Prevention of Component 1: Prevention of Stunting at Community and 35000000.00 Revised Stunting at Community and 34800000.00 Household Levels Household Levels Component 2: High-impact Component 2: High-impact 14500000.00 Revised 12000000.00 Health and Nutrition Services Health and Nutrition Services Component 3: Monitoring and Component 3: Monitoring and Evaluation, and Program 5500000.00 Evaluation, and Program 5500000.00 Management Management CERC 0.00 Revised CERC 2700000.00 55,000,000. TOTAL 55,000,000.00 00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-61870-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: Gds,NonCS,CS Pt 1(i) 710,000.00 0.00 456,088.00 25.00 25.00 iLap Category Sequence No: 2 Current Expenditure Category: Gds,NonCS,CS&Trg Pt 1(ii) 1,410,000.00 7,513.32 693,955.00 0.00 0.00 iLap Category Sequence No: 3 Current Expenditure Category: Performance Based Pymts Pt1iii 4,450,000.00 2,140,218.30 3,471,572.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: Gds,NonCS,CS,Tr,OC Pt1iv&v &3iii The World Bank Stunting Prevention and Reduction Project (P164845) 4,000,000.00 3,041,746.56 4,000,000.00 100.00 100.00 iLap Category Sequence No: 5 Current Expenditure Category: Gds,NonCS,CS&Trg Pt1(iv) 1,410,000.00 335,207.97 1,410,000.00 100.00 100.00 iLap Category Sequence No: 6 Current Expenditure Category: Gds,CS,NonCS,Trg Pt 1vii 5,620,000.00 5,559,171.93 5,620,000.00 100.00 100.00 iLap Category Sequence No: 7 Current Expenditure Category: Emergency Expenditures prt 4 0.00 0.00 1,948,385.00 100.00 100.00 Total 17,600,000.00 11,083,858.08 17,600,000.00 TF-A6567-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: Gds,NonCS,CS &Tr Pt 1(i) 3,000,000.00 1,033,418.71 3,000,000.00 75.00 75.00 iLap Category Sequence No: 2 Current Expenditure Category: Gds,NonCS,CS&Trg Pt 2(ii) 11,000,000.00 3,308,796.57 8,500,000.00 100.00 100.00 iLap Category Sequence No: 3 Current Expenditure Category: Performance Based Pymts Pt2i 3,500,000.00 3,500,000.00 3,500,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: Gds,NonCS,CS,Tr Pt3i&3ii 2,500,000.00 20,162.00 2,500,000.00 0.00 0.00 iLap Category Sequence No: 5 Current Expenditure Category: Goods-FBF 0.00 0.00 2,500,000.00 100 The World Bank Stunting Prevention and Reduction Project (P164845) Total 20,000,000.00 7,862,377.28 20,000,000.00 . The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) . Results framework COUNTRY: Rwanda Rwanda Stunting Prevention and Reduction Project Project Development Objectives(s) The proposed Project Development Objective (PDO) is to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target To contribute to reduction in the stunting rate among children under five in the target districts (Action: This Objective has been Revised) Indicator 1a: Percentage of children under 5 years with height- 43.60 32.00 for-age z-score below -2 standard deviations (Percentage) Indicator 1b: Percentage of children under 2 years with height- 37.10 27.20 for-age z-score below -2 standard deviations (Percentage) Indicator 2: Percentage of children 6-23 months old who are fed 22.90 50.00 a diverse diet (Percentage) Indicator 3: Percentage of women who attended 4 or more ANC 36.00 55.00 visits during their most recent pregnancy (Percentage) People who have received essential health, nutrition, and 0.00 1,660,000.00 population (HNP) services (CRI, Number) Number of women and children who have received basic 0.00 1,660,000.00 nutrition services (CRI, Number) Indicator 4a: Number of children under 5 were beneficiaries 0.00 560,000.00 of project interventions (Number) The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline End Target Indicator 4b: Number of women of reproductive age (including pregnant and lactating women) who were 0.00 1,100,000.00 beneficiaries of project interventions (Number) Indicator 4: Percentage of Ports of Entry which are operational 0.00 100.00 (Percentage) Action: This indicator is New PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target Component 1: Prevention of Stunting at Community and Household Levels IRI 1: Percentage of home-based ECD centers with satisfactory 0.00 80.00 scores on quality score card (Percentage) IRI 2: % of CHWs who received a quarterly supportive supervision 40.00 80.00 visit from HC (Percentage) IRI 3: Percentage of pregnant women who attended the first ANC 40.00 70.00 visit during the first trimester (Percentage) IRI 4: Percentage of pregnant women with anemia (Percentage) 2.00 1.00 IRI 5: Percentage of participants at CHW education sessions surveyed who demonstrate knowledge of proper care, feeding, 0.00 50.00 and WASH practices (Percentage) IRI 6: Percentage of children 6-23 months old receiving 0.00 90.00 micronutrient powders (Percentage) The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target IRI 7: Percentage of children under two with diarrhea treated 0.00 50.00 with ORS and zinc. (Percentage) IRI 8: Number of Ubudehe 1 households with improved latrines 0.00 5,500.00 (from project interventions) (Number) IRI 9: Number of districts with satisfactory ratings on the DPEM 0.00 13.00 activity scorecard (to be developed) (Number) Component 2: High-impact Health and Nutrition Services IRI 10: Percentage of children under 5 with height measured and 0.00 75.00 recorded at health facility (Percentage) IRI 11: Percentage of CHWs with no stock out of Zinc for diarrhea 0.00 100.00 treatment. (Percentage) IRI 12: Percentage of women of reproductive age who are new 0.00 60.00 acceptors of modern contraceptives (Percentage) IRI 13: Percentage of fortified blended food (FBF) distribution 0.00 100.00 centers with no stock outs in the previous quarter. (Percentage) IRI 14: Percent of eligible pregnant and lactating women from ubudehe 1 & 2 households who consumed FBF in the past 24 0.00 80.00 hours. (Percentage) IRI 15: Percentage of children 6-23 months old who consumed 0.00 75.00 FBF in the past 24 hours (Percentage) Component 3: Monitoring and Evaluation, and Program Management IRI 16: Percentage of participating health facilities that receive satisfactory rating from women and caregivers whose children 0.00 90.00 received nutrition services (Citizen Engagement indicator) (Percentage) IRI 17: Number of peer learning events conducted (within and 0.00 25.00 between districts and sectors) (Number) The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline End Target CERC (Action: This Component is New) IRI 18: Percentage of designated hospitals with isolation capacity 0.00 100.00 (Percentage) Action: This indicator is New IO Table SPACE