FOR OFFICIAL USE ONLY Report No: PADHI00394 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT AND INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON ON A PROPOSED CREDIT IN THE AMOUNT OF US$120 MILLION TO THE REPUBLIC OF RWANDA FOR THE RWANDA HEALTH EMERGENCY PREPAREDNESS, RESPONSE AND RESILIENCE PROJECT USING THE MULTIPHASE PROGRAMMATIC APPROACH (PHASE 4) APPROVED BY THE BOARD ON SEPTEMBER 29, 2023, WITH AN OVERALL IDA ENVELOPE OF US$1 BILLION EQUIVALENT AND PROPOSED TO BE INCREASED TO US$1.5 BILLION EQUIVALENT May 3, 2024 Health, Nutrition & Population Global Practice Eastern And Southern Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective March 31, 2024 Currency Unit Rwandan Franc = RWF. 1,286.00 RWF = US$1.00 FISCAL YEAR January 1 – December 31 Regional Vice President: Victoria Kwakwa Regional Director: Daniel Dulitzky Country Director: Keith E. Hansen Practice Manager: Francisca Ayodeji Akala Ramesh Govindaraj, Amparo Elena Gordillo-Tobar, Joao Verissimo Task Team Leaders: Figueiredo Rodrigues E Pires, Nkosinathi Vusizihlobo Mbuya ABBREVIATIONS AND ACRONYMS AFE Eastern and Southern Africa AFRO Regional Office for Africa AWPB Annual Work Plan and Budget CERC Contingent Emergency Response Component CHW Community Health Worker DRC Democratic Republic of Congo E&S Environment and Social ESS Environmental and Social Standards ECSA-HC East, Central, and Southern Africa Health Community ESMF Environmental and Social Management Framework FM Financial Management GHG Greenhouse Gas GRS Grievance Redress Service HE Health Emergencies HEPRR Health Emergency Preparedness, Response and Resilience IDA International Development Association IGAD Intergovernmental Authority on Development JEE Joint External Evaluation MCH Maternal and Child Health MPA Multiphase Programmatic Approach MTR Mid-Term Review MWMP Medical Waste Management Plan NCD Noncommunicable disease NHEROP National Health Emergency Response Operations Plan PAD Project Appraisal Document PDO Project Development Objective PrDO Program Development Objective PIM Project Implementation Manual RBC Rwanda Biomedical Centre MNCH Maternal Neonatal Children Health SDG Sustainable Development Goal SLIPTA Stepwise Laboratory Improvement Process SPIU Single Project Implementation Unit TA Technical Assistance WHO World Health Organization The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) TABLE OF CONTENTS DATASHEET ........................................................................................................................... ii I. STRATEGIC CONTEXT ...................................................................................................... 9 A. Country Context ................................................................................................................................ 9 B. Sectoral and Institutional Context .................................................................................................... 9 C. Relevance to Higher Level Objectives ............................................................................................. 10 D. Multiphase Programmatic Approach.............................................................................................. 11 II. PROJECT DESCRIPTION.................................................................................................. 15 A. Project Development Objective ...................................................................................................... 15 B. Project Components ....................................................................................................................... 15 C. Project Beneficiaries ....................................................................................................................... 18 D. Rationale for Bank Involvement and Role of Partners ................................................................... 18 E. Lessons Learned .............................................................................................................................. 18 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 19 A. Institutional and Implementation Arrangements ........................................................................... 19 B. Results Monitoring and Evaluation Arrangements ......................................................................... 19 C. Sustainability ................................................................................................................................... 19 D. Alignment with Corporate Commitments ...................................................................................... 20 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 21 A. Technical, Economic and Financial Analysis .................................................................................. 21 B. Fiduciary .......................................................................................................................................... 22 C. Legal Operational Policies ............................................................................................................... 23 D. Environmental and Social ............................................................................................................... 23 V. GRIEVANCE REDRESS SERVICES ..................................................................................... 24 VI. KEY RISKS...................................................................................................................... 24 VII. RESULTS FRAMEWORK AND MONITORING ................................................................... 26 ANNEX 1: Implementation Arrangements and Support Plan ................................................. 33 ANNEX 2: Climate Change .................................................................................................... 35 i The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) @#&OPS~Doctype~OPS^dynamics@padbasicinformation#doctemplate DATASHEET BASIC INFORMATION Project Operation Name Beneficiary(ies) Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Rwanda Multiphase Programmatic Approach Environmental and Social Risk Operation ID Financing Instrument Classification Investment Project P504764 Substantial Financing (IPF) @#&OPS~Doctype~OPS^dynamics@padmpaprocessing#doctemplate Financing & Implementation Modalities [✓] 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 [ ] Alternative Procurement Arrangements (APA) [ ] Hands-on Expanded Implementation Support (HEIS) Expected Approval Date Expected Closing Date Expected Program Closing Date 21-May-2024 31-Mar-2030 30-Sep-2030 Bank/IFC Collaboration No @#&OPS~Doctype~OPS^dynamics@padmpa#doctemplate MPA Program Development Objective The MPA Program Development Objective (PrDO) is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in Eastern and Southern Africa. MPA FINANCING DATA (US$, Millions) ii The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) MPA Program Financing Envelope 1,500.00 with an additional request to IBRD 190.00 with an additional request to IDA 310.00 Proposed Development Objective(s) The PDO is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in the Republic of Rwanda. Components Component Name Cost (US$) Component 1: Strengthening the Preparedness and Resilience of the Health 65,600,000.00 System to manage HEs Component 2: Improving early detection of and response to HEs through a 49,400,000.00 multisectoral approach Component 3: Project Management 5,000,000.00 Component 4: Contingent Emergency Response 0.00 Organizations Borrower: The Republic of Rwanda Implementing Agency: Rwanda Biomedical Centre MPA FINANCING DETAILS (US$, Millions) Board Approved MPA Financing Envelope 1,000.00 MPA Financing Envelope: 1,500.00 of which Bank Financing (IBRD): 190.00 of which Bank Financing (IDA): 1,310.00 of which Other Financing sources: 0.00 @#&OPS~Doctype~OPS^dynamics@padfinancingsummary#doctemplate PROJECT FINANCING DATA (US$, Millions) Maximizing Finance for Development Is this an MFD-Enabling Project (MFD-EP)? No iii The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Is this project Private Capital Enabling (PCE)? No SUMMARY Total Operation Cost 120.00 Total Financing 120.00 of which IBRD/IDA 120.00 Financing Gap 0.00 DETAILS World Bank Group Financing International Development Association (IDA) 120.00 IDA Credit 120.00 IDA Resources (US$, Millions) Guarantee Credit Amount Grant Amount SML Amount Total Amount Amount National Performance-Based 120.00 0.00 0.00 0.00 120.00 Allocations (PBA) Total 120.00 0.00 0.00 0.00 120.00 @#&OPS~Doctype~OPS^dynamics@paddisbursementprojection#doctemplate Expected Disbursements (US$, Millions) WB Fiscal Year 2024 2025 2026 2027 2028 2029 2030 Annual 20.00 35.00 20.00 20.00 10.00 10.00 5.00 Cumulative 20.00 55.00 75.00 95.00 105.00 115.00 120.00 @#&OPS~Doctype~OPS^dynamics@padclimatechange#doctemplate PRACTICE AREA(S) iv The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Gender CLIMATE Climate Change and Disaster Screening Yes, it has been screened and the results are discussed in the Operation Document @#&OPS~Doctype~OPS^dynamics@padrisk#doctemplate SYSTEMATIC OPERATIONS RISK- RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Moderate 2. Macroeconomic  Moderate 3. Sector Strategies and Policies  Moderate 4. Technical Design of Project or Program  Substantial 5. Institutional Capacity for Implementation and Sustainability  Substantial 6. Fiduciary  Moderate 7. Environment and Social  Substantial 8. Stakeholders  Substantial 9. Overall  Substantial Overall MPA Program Risk  Substantial @#&OPS~Doctype~OPS^dynamics@padcompliance#doctemplate POLICY COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No v The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) ENVIRONMENTAL AND SOCIAL Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance ESS 1: Assessment and Management of Environmental and Social Risks and Relevant Impacts ESS 10: Stakeholder Engagement and Information Disclosure Relevant ESS 2: Labor and Working Conditions Relevant ESS 3: Resource Efficiency and Pollution Prevention and Management Relevant ESS 4: Community Health and Safety Relevant ESS 5: Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant ESS 6: Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources ESS 7: Indigenous Peoples/Sub-Saharan African Historically Underserved Not Currently Relevant Traditional Local Communities ESS 8: Cultural Heritage Relevant ESS 9: Financial Intermediaries Not Currently Relevant NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). @#&OPS~Doctype~OPS^dynamics@padlegalcovenants#doctemplate LEGAL Legal Covenants Sections and Description Section I.D. 1 and 5 of Schedule 2 to the Financing Agreement and Section I.D of the Schedule to the Project Agreement: The Recipient shall, through the Project Implementing Entity, prepare and furnish to the Association not later than March 31 of each Fiscal Year during the implementation of the Project, a consolidated work plan and budget containing inter alia: (i) all activities proposed to be implemented under the Project during the following Fiscal Year; (ii) a proposed financing plan for expenditures required for such activities, setting forth the proposed amounts and sources of financing therefor and disbursement schedule; and (iii) the training plan for such period. […] Without limitation on the provisions of this Section, the Recipient shall prepare and furnish to the Association the first proposed Annual Work Plan and Budget required under the Project not later than one month after the Effective Date. Section I.G of Schedule 2 to the Financing Agreement: In order to maximize the benefits of regional harmonization for purposes of the Project, no later than three months after the Effective Date, the Recipient shall enter into a separate memorandum of understanding with each of the Regional Bodies (the “MOU”, or in the case of separate memoranda, each an “MOU”), in form and substance satisfactory to the Association, as such MOU shall include provisions to the vi The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) effect of ensuring that the Recipient shall participate in any activity carried out by the Regional Bodies under the MPA, including inter alia training events, workshops, data collection and analysis or knowledge-sharing. @#&OPS~Doctype~OPS^dynamics@padconditions#doctemplate Conditions Type Citation Description Financing Source Section 4.01 of Article IV of the Financing Agreement: The Additional Conditions of Effectiveness consist of the following: (a) The Subsidiary Agreement has been executed on behalf of the Recipient and the Project Implementing Entity and all conditions precedent to its effectiveness, save for the Effectiveness Effectiveness Conditions IBRD/IDA effectiveness of this Agreement, shall have been met; and (b) The Recipient, through the Project Implementing Entity, has adopted the Project Implementation Manual in accordance with Section I.C of Schedule 2 to this Agreement and in form and substance satisfactory to the Association. Section III.B of Schedule 2 to the Financing Agreement: Notwithstanding the provisions of Part A of this Section, no withdrawal Disbursement Disbursement Conditions shall be made: (a) for IBRD/IDA payments made prior to the Signature Date or; (b) for Emergency Expenditures under Category (2), unless and until all of the following vii The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) conditions have been met in respect of said expenditures: (i) (A) the Recipient has determined that an Eligible Crisis or Emergency has occurred, and has furnished to the Association a request to withdraw Financing amounts under Category (2); and (B) the Association has agreed with such determination, accepted said request and notified the Recipient thereof; and (ii) the Recipient has adopted the CERC Manual and Emergency Action Plan, in form and substance acceptable to the Association. viii The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) I. STRATEGIC CONTEXT Introduction 1. This project document seeks the approval of the Executive Directors on a proposed credit in the amount of US$120 million to the Republic of Rwanda as part of Phase 4 of the Health Emergency Preparedness, Response and Resilience Program using a Multiphase Programmatic Approach (MPA). The MPA was approved by the World Bank’s Board of Directors on September 29, 2023, with an overall IDA envelope of US$1 billion equivalent. The request also seeks the approval to increase the MPA financing envelope to US$1.5 billion equivalent for nine new countries that have expressed interest in the program, adding up to US$0.5 billion to the program financing envelope. The Program Development Objective (PrDO) for the MPA remains unchanged and is “to strengthen health system resilience and multisectoral preparedness and response to health emergencies (HEs) in Eastern and Southern Africa (AFE). Likewise, MPA Components, PrDO indicators, and the menu of activities and of results indicators, will not change. A. Country Context 2. With a resilient economy and significant progress on the health-related Sustainable Development Goals (SDGs), Rwanda is committed to health system strengthening and doing more to manage HEs. The economy grew by 7.6 percent in the first three quarters of 2023, in the face of global monetary stringency, challenging financial conditions, and downturns in international trade. This was fueled by a resurgence in investment and steady household consumption. Growth is expected to regain momentum, increasing by 7.2 percent on average in 2024–26. 3. Rwanda, ranked 112 out of 185 countries in the 2021 Notre Dame-Global Adaptation Index2, is recognized as vulnerable to climate change and is suffering from a range of health impacts as a result. The country is particularly vulnerable to flooding, high heat, drought, and landslides which are expected to increase in frequency and severity. The country has already experienced a temperature increase of 1.4°C since 1970, higher than the global average; and an increase of up to 2.0°C is expected by the 2030s. The temperature rise is expected to be consistent across the country and seasons—although the increase during the long dry season may be slightly higher than in other seasons. Severe flooding and landslides in early May 2023 claimed many lives and damaged provincial health care and water, sanitation, and hygiene (WASH) infrastructure, resulting in a wide range of negative health outcomes. Climate change is expected to increase the prevalence of water and vector-borne diseases (for example, malaria, dengue). Malaria is the third leading cause of death and disability in Rwanda and one of the leading causes of under-five mortality. Changes in heat and precipitation will make previously malaria-free highlands more susceptible to outbreaks. B. Sectoral and Institutional Context 4. Rwanda continues to advance toward the SDGs targets, showcasing improvements in most health and wellbeing indicators. The country’s life expectancy increased from 51.2 years in 2002 to 69.6 years in 2022. National maternal and child survival outcomes surpass the sub-Saharan averages by almost half, with under-five child mortality estimated at 39.4 per 1,000 live births, and maternal mortality at 259 per 100,000 live births in 2021. Coverage of at least one antenatal care visit can be regarded as universal (98 percent); similarly, nearly all pregnant women are tested for HIV, 94 percent of deliveries take place in health facilities, and more than 96 percent of infants and toddlers ages 12 to 23 months are vaccinated. Additionally, the use of modern contraception, especially among married women, has increased to almost 60 percent, while the proportion of women benefiting from postnatal care has risen to 70 percent. 5. Despite notable achievements, Rwanda's public health system still faces critical gaps in quality of care, and access in remote locations. Although the SDG target on acute malnutrition (wasting) has already been met, and some declines Page 9 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) in chronic malnutrition (stunting) have been recorded, the stunting rate remains stubbornly high at 33 percent, with children of ages 24–35 months of age worst affected. A higher proportion of children in rural areas (36 percent) and in the lowest wealth quintile (49 percent) are stunted, as compared with 20 percent of children in urban areas and 11 percent in the highest quintile. The proportion of children ages 6–59 months who are anemic stagnated at 37 percent, and exclusive breastfeeding declined from 87 to 81 percent over the last five years. Additionally, an estimated 39 percent of women in unions (that is, cohabiting) have an unmet need for family planning services. Access to these services among adolescent girls remains suboptimal, with an estimated 32 births per 1,000 among girls ages 15–19 in 2021. While Gavi- supported Human papillomavirus vaccination programs reported a coverage of 98 percent of eligible girls between 2011 and 2018, cervical cancer ranks as the second most frequent cancer among women in Rwanda and the most frequent cancer among women between 15 and 44 years of age with a crude incidence rate of 18.7 cases per 100,000 population, associated with the deaths of 829 women per year. Furthermore, Rwanda—like other countries—faces an increasing burden of other noncommunicable diseases (NCDs) such as diabetes, hypertension, and mental health conditions. Delivery models for these conditions are not as well developed, as became evident during the COVID-19 pandemic. 6. Epidemics, emerging and re-emerging diseases, and climate change significantly impact the well-being of the population and are of great concern to the government. During the COVID-19 pandemic, utilization of routine maternal and child health services declined on 13 indicators across all five provinces in Rwanda. Severe floodings and landslides in early May 2023 claimed 135 lives and caused significant damage to provincial health care and WASH infrastructure, resulting in a wide range of negative health outcomes. In addition, these climate events damaged roads and bridges, limiting and, in some cases, completely interrupting the provision of services due to inability to maintain health equipment and distribute medication and health supplies. Climate change is expected to increase the prevalence of water and vector-borne diseases such as malaria and dengue. Malaria is already the third leading cause of death and disability in Rwanda and one of the leading causes of under-five mortality. Changes in heat and precipitation will make the previously malaria-free highlands more susceptible to outbreaks during the coming decades. 7. Rwanda’s vision 2050 is in alignment with the Wealth Health Organization’s (WHO) assessment of the Africa region. WHO- Regional Office for Africa (AFRO) has worked closely with Member States and international partners to develop the human resources and logistical capabilities necessary to rapidly identify and effectively respond to disease risks. This involves streamlining public health institutional arrangements to enhance coordination and response capabilities. The country’s approach includes innovations in health care delivery and the establishment of the National Public Health Institute, signaling its commitment to a robust and integrated health system to respond as well as a One Health approach 1, bridging gaps in the existing fragmented public health system. Rwanda has recently launched a “4 x 4” strategy that seeks to quadruple the number of health workers in four years and close gender gaps in the health care workforce. Rwanda recognizes the need to improve its capabilities for laboratory work and research and in doing so to reduce reliance on imported health products. Ongoing initiatives focus on strengthening local manufacturing capacities, particularly in messenger Ribonucleic Acid (mRNA) vaccine production. This aligns with Rwanda's commitment to health security and self-sufficiency. C. Relevance to Higher Level Objectives 8. The objectives and design of the project (Phase 4 of the MPA) are consistent with: (i) the priority areas articulated in the country’s Health Sector Policy in Rwanda’s Fourth Health Sector Strategic Plan (2018–2024) 2, and the new Health Sector Strategic Plan under preparation (2024–2029) which prioritizes building health security and a resilient system; and 1Based on a One Health Policy prepared on March 2021 from the lessons learned in the prevention and response to Ebola and COVID-19 2Fourth Health Sector Strategic Plan. July 2018-June 2024. Ministry of Health. Republic of Rwanda. https://www.minecofin.gov.rw/index.php?eID=dumpFile&t=f&f=15856&token=7aabf4f0ec53ed2685b9bd0a1f9df78a60651a35 Page 10 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) (ii) the implementation of Rwanda’s Five-Year National Action Plan for Health Security (NAPHS: 2020–2024) 3, whose goal is to address holistically health security and emergencies capabilities within the country using a “One Health Concept.” The One Health approach will ensure that there is timely preparedness, rapid detection, and a consistent and coordinated response to health risks. Here, the emergence and re-emergence of zoonotic diseases—resulting from a broader interface between humans and animals—will pull together the efforts of key ministries in health, agriculture, livestock, environment, among others. The project will also complement the implementation of the National Health Emergency Response Operations Plan (NHEROP), which offers the health sector comprehensive guidance, enlisting key stakeholders, communities—and political support—to promote immediate, cohesive action under clearly defined leadership across systems and sectors. In addition, the objectives are consistent with the World Bank Group Country Partnership Framework for Rwanda for Fiscal Year (FY) 21–26, discussed by the Board on July 9, 2020 (Report No. 148876-RW). The project will contribute to the Country Partnership Framework - Objective 1 (Improving Human Capital), which recognizes that “a healthy, and well-educated and skilled labor force is essential to Rwanda’s future prospects and inclusive growth.” 9. The project is aligned with the World Bank’s mission, and key World Bank regional and global strategies. Phase 4 is aligned with the IDA20 commitments, the AFE Regional priorities, and the World Bank’s Africa Regional Integration and Cooperation Assistance Strategy (FY21–FY23), whose December 2020 update underscored “preparing for pandemics and disease outbreaks” and “reinforcing resilience to shocks and promoting effective management of challenges that cut across boundaries.” Phase 4 will contribute to the World Bank’s Climate Change Action Plan 2021–2025, which lays the foundation for the World Bank’s Green, Resilient, and Inclusive Development approach. 10. Phase 4 is consistent with both the adaptation and mitigation goals of the Paris Agreement, and Rwanda’s Nationally Determined Contribution (NDC, updated 2020). The updated NDC sets out a target of a 38 percent (4.6 million tCO2e) reduction in greenhouse gas (GHG) emissions by 2030 in comparison to a business-as-usual scenario. The project is expected to make a considerable contribution to improving climate adaptation and resilience in line with the Paris Agreement and is not expected to contribute to GHG emissions. The project is therefore aligned with Rwanda’s commitment to reduction of GHG as outlined in the country’s NDC, National Environment and Climate Change Policy (2019), National Strategy on Climate Change and Low Carbon Development for Rwanda (2011), and Strategic Programme for Climate Resilience (2017). Furthermore, the project is consistent with the Fourth Health Sector Strategic Plan (2018– 2024), and the National Adaptation Plan (2021), which stress the impacts of climatic hazards on escalating the prevalence and burden of climate-sensitive diseases (water and vector-borne diseases), and damage to critical infrastructure, and outline adaptation measures accordingly. D. Multiphase Programmatic Approach 11. Phase 4 of the Health Emergency Preparedness, Response and Resilience Program using a Multiphase Programmatic Approach (MPA) will support the Republic of Rwanda with a credit in the amount of US$120 million. In addition, the MPA approved by the World Bank’s Board of Directors on September 29, 2023, with an overall IDA envelope of US1 billion equivalent will be increased to US$1.5 billion equivalent. a) The first phase of the MPA (P180127) provided financing to Kenya, Ethiopia, São Tomé and Príncipe, the East, Central and Southern Africa Health Community (ECSA-HC), and the Intergovernmental Authority on Development (IGAD). Both phase 2 (IDA credit in the amount of US$250 million to Democratic Republic of Congo - DRC) (P504532) and phase 3 (IDA grant to Burundi in the amount of US$50 million equivalent) (P504531) were approved 3National Action Plan for Health Security. 2020-2024. Rwanda Biomedical Centre. Ministry of Health. Republic of Rwanda. https://www.rbc.gov.rw/fileadmin/user_upload/report23/NAPHS%202020-2024.pdf Page 11 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) on March 30, 2024. Phase 4 will add Rwanda and nine new countries 4 to the program and significantly expand the World Bank support for health emergency preparedness in the region. The original MPA financing envelope is insufficient to respond to the immediate needs of countries under the program. Additionally, the geographical expansion will bring to fruition the regional learning agenda and increase regional integration through policy harmonization, peer-to-peer learning/South-South knowledge exchange, and improved research coordination. b) There will be no changes to the MPA Components, PrDO indicators, and the menu of activities and results indicators. The new country projects will choose relevant activities from the approved Program components (menu of activities) for their country projects. To measure country-level progress, country projects will identify relevant indicators from the list of approved program indicators. They will add others as needed but within the scope of the program’s results chain. The MPA is progressing in phases; the sequencing reflects the needs, requests, and readiness of countries under the program (Table 1). 4 The following nine countries have expressed interest in the MPA: Angola, Botswana, Lesotho, Malawi, Mozambique, Rwanda, South Sudan, Tanzania, and Zambia. Page 12 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Table 1. Health Emergency Preparedness, Response and Resilience Program (HEPRR) Framework Overview Estimated Estimated IBRD IDA Estimated Estimated MPA Sequential or IPF or Operation ID Phase’s Proposed DO* Amount Amount Approval Environmental & Phase # Simultaneous PforR (US$ (US$ Date Social Risk Rating Million) Million) P180127 Phase I MPA: “To strengthen health system (Ethiopia, Kenya, resilience and multisectoral preparedness and 1 São Tomé and Simultaneous IPF 0.00 359.00 09/29/2023 Substantial response to health emergencies in Eastern and Príncipe, ECSA-HC Southern Africa.” ( PAD5376) and IGAD) Phase 2 MPA: Congo Democratic Republic (ZR): “To strengthen health system resilience and P504532 2 multisectoral preparedness and response to Simultaneous IPF 0.00 250.00 03/29/2024 Moderate (DRC) health emergencies in the Democratic Republic of the Congo” (PADHI00392) Phase 3 MPA: Burundi (BI): “To strengthen health system resilience and multisectoral 3 P504531 (Burundi) preparedness and response to health Simultaneous IPF 0.00 50.00 03/29/2024 Moderate emergencies in the Republic of Burundi” (PADHI00379) Phase 4 MPA: Rwanda:” To strengthen Rwanda's health system resilience, multisectoral 4 P504764 (Rwanda) Simultaneous IPF 0.00 120.00 05/21/2024 Substantial preparedness, and response to health emergencies. Angola (US$150 million), Botswana (US$40 million), Lesotho (US$11 million), Malawi (US$100 million), Mozambique (US$100 million), New Borrowers* Simultaneous 190.00 531.00 Rwanda (US$120 million), South Sudan (US$20 million), Tanzania (US$150 million), and Zambia (US$100 million) Total amount financing for participanting countries 190.00 1,310 Page 13 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Original Board approved financing envelope US$1,000 million Additional financing amount for MPA US$500 million Total revised overall MPA financing envelope US$1,500 million * Financing and their sources, including from IDA will be determined during preparation/appraisal. Page 14 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) II. PROJECT DESCRIPTION A. Project Development Objective (i) Project Development Objective (PDO) Statement 12. The PDO is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in the Republic of Rwanda. (ii) PDO-Level Indicators 13. The PDO will be measured through the following key indicators that are picked from the menu of results indicators of the AFE HEPRR Program: Table 2. PDO Indicators PDO level Indicators Baseline End Target The average score of 3.5 in at least 3 JEE core capacity area in the Prevent axis (Number) 2.5 3.5 The average score of 3.5 in at least 3 JEE core capacity areas in the Detect axis (Number) 1.5 3.5 The average score of 3.5 in at least 3 JEE core capacity areas in the Respond axis (Number) 2.5 3.5 The detected health events, where the country met the 7-1-7 target (Percentage) 70 95 Project-supported laboratories that have achieved a 3-star rating or higher during a Stepwise 30 90 Laboratory Improvement Process (SLIPTA) audit (Percentage) B. Project Components 14. The project comprises four complementary components: 15. Component 1: Strengthening the Preparedness and Resilience of the Health System to manage Health Emergencies (HEs) (US$65.6 million). The Component comprises four subcomponents and will support multisectoral collaboration between health and other line ministries: 16. Subcomponent 1.1: Multisectoral cross-border planning, financing, and governance for improved resilience to HEs. 5 This subcomponent will: (i) strengthen the existing One Health Multisectoral Coordination Mechanism; (ii) develop a costed and financed national multisectoral action plan for One Health; (iii) strengthen cross-border response, including the expansion of the cross-border functional surveillance systems at points of entry with the corresponding training (climate change is a primary impetus and focus of these activities); and (iv) strengthen infection prevention and control initiatives that ensure appropriate guidance and measures at health facilities within districts at the borders to better address the antimicrobial resistance burden. 17. Subcomponent 1.2: Health workforce skills development. This subcomponent aims to strengthen existing capabilities, harmonizing knowledge and skills and building specialized diagnostic skills and capacity among the health workforce for advanced technologies while addressing gender gaps. It will seek to: (i) establish a gender- sensitive training 5 The health and non-health line ministries involved in the implementation of this component are described in the implementation section. Page 15 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) program to ensure gender inclusivity in Science, Technology, Engineering, and Mathematics (STEM); 6 (ii) establish a specialized training program to offer state-of-the-art training on advanced biomedical sciences and instrumentation used in cutting-edge diagnostics including bioengineering, molecular and immunological techniques and using energy-efficient and climate-adaptive building designs as well as local materials; (iii) develop project-based mentorship initiatives led by university-affiliated faculty who will provide selected graduate students (keeping in mind inclusion of female graduate students and students from climate-vulnerable areas as feasible) with hands-on opportunities to develop diagnostic assays responding to unmet clinical needs; (iv) train additional professionals such as field epidemiologists, data scientists, bioinformaticians and laboratory professionals, under an equity lenses for gender and inclusion of professionals from climate-vulnerable areas as feasible; (v) develop and execute a focused climate and health emergency preparedness and response training; and (vi) develop a system for health workforce surge capacity during climate shocks and HEs to ensure health workers are distributed adequately where most needed without leaving essential services unattended. 18. Subcomponent 1.3: Building capacity for the National Health Institute and improving access to quality health commodities. This subcomponent aims to strengthen Rwanda’s capacity to develop, produce, and deploy quality diagnostics for priority health threats. Key investments will include: (i) the expansion of the Rwanda Biomedical Centre as the National Health Institute of the country 7 into the Diagnostics Development and Research Centre using energy efficient and climate and gender-adaptive building designs as well as local materials. It will drive innovation of affordable diagnostic solutions targeting leading regional infectious disease threats including emerging/re-emerging epidemics like Rift Valley fever, typhoid, Ebola, and vaccine-preventable diseases like measles. It will support the translation of promising technologies into quality-assured diagnostic products for domestic use and export; (ii) the expansion of the National Health Institute to include the One Health Laboratory and Biobank facility for testing emerging and re-emerging pathogens, including development of national reference standards to manage climate- sensitive disease outbreaks; (iii) technical assistance (TA) to review national laws and other applicable rules on storage, distribution, and control, to determine the adequacy of the technical, legal and regulatory frameworks and its consistency with international best practice; identify any gaps, and implement measures for filling those gaps; (iv) TA on the development of a One Health laboratory in Rwanda including risk management and human resource development; (v) strengthening the capacity of the National Regulatory Agencies and Regional Centers of Regulatory Excellence; and (vi) TA to develop a five-year roadmap, plans of action, and strategy to guide the functioning of the centers (Diagnostics Development and Research Center, One Health Laboratory and Biobank facility) and lead the implementation of enhanced quality laboratory protocols. 19. Subcomponent 1.4: Information systems for HEs and the digitalization of the health sector. This subcomponent aims to strengthen real time surveillance and decision support capabilities, leveraging artificial intelligence and advanced analytics. Key activities include: (i) establishing digital disease surveillance platforms across institutions that include village-based registries of health risks from human, animal, and environmental sources, incorporating gender-specific demographics (age, sex, pregnancy status) to enable early outbreak detection, establishing and updating them on an annual basis. In addition, establishing climate change risks is a primary impetus and focus of this activity; (ii) building interactive data visualization tools for policymakers that overlay predictive models with assets and resources data to aid risk communication and response planning that can be gender-specific as relevant, such that modelling of climate change impacts remains a primary impetus and focus of this activity; (iii) improving the quality and reliability of data and geographic coverage of existing digital health information platforms; this includes ensuring complete and accurate data on key demographics such as sex, age and (for women 15–49 years of age) pregnancy status, and ensuring coverage of 6 That is, one which will ensure an equitable sex ratio of participants in computational diagnostics to develop expertise in leveraging artificial intelligence (AI), big data, bioinformatics, and machine learning to design high-performance diagnostics tailored to health emergencies, specifically priority diseases and climate change induced shocks. 7 “Project Implementing Entity”, “Rwanda Biomedical Centre” or “RBC” means the Recipient’s national health institute. Page 16 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) the most remote and vulnerable areas of the country; (iv) establishing real-time monitoring systems of facility service availability and readiness to monitor the disruption to essential health services; and (v) integrating meteorologic and air- quality related data into the surveillance and health information system. 20. Component 2: Improving early detection of and response to HEs through a multisectoral approach (US$49.4 million). This component will support operational readiness and capacities across critical subsystems to effectively detect and respond to national, regional, and global HEs. The component has three subcomponents. 21. Subcomponent 2.1: Collaborative multisectoral gender-responsive surveillance and laboratory diagnostics. Major investment under this subcomponent will include: (i) establishing an emergency operations center on a permanent basis to coordinate health security efforts with integrated data dashboards for gender-disaggregated surveillance to prepare for and respond to climate shocks or other sources of HEs. It includes developing capacity to quickly reorganize and utilize alternative service-delivery platforms to prevent service disruption during emergencies, and the development of facility- level climate emergency preparedness and response plans; (ii) expanding multipathogen testing and sequencing abilities to better characterize and monitor the dynamics of public health threats; and (iii) strengthening environmental surveillance systems to monitor wastewater for emerging and re-emerging public health threats like COVID-19, polio, mpox, cholera, and so forth. 22. Subcomponent 2.2: Emergency management, coordination, and essential service continuity. This subcomponent will ensure the readiness and quality of essential services provided to the population and the continuity of services and coordination across levels of care to respond to HEs. The primary focus will be on service continuity during climate shocks and HEs given their level of disruption to health services. Under this subcomponent, the project will finance the following activities: (i) Improving the quality of maternal, newborn, child and adolescent health services, including the optimization of existing Maternal Neonatal Children Health (MNCH) 8 interventions, as well as the adoption and implementation of MNCH bundles and innovations. It includes supporting, rehabilitating, renovating and upgrading eight existing health centers to “Medicalized Health Center” level facilities in selected remote areas and hard-to-access district hospitals, equipment and implementation of norms and procedures for Maternal and Child Health (MCH), NCDs, Mental Health and HE; and (ii) Strengthening mental health preparedness and response capacity for public HEs, including the case management for referral systems for standard and HE cases including the transfer system for MNCH emergencies, worsening NCD cases and quick assistance to suspected cases of pandemic-prone diseases. It includes well-equipped ambulances and staff trained in emergency neonatal care, obstetric care, and basic life support. 23. Subcomponent 2.3: Risk communication and community engagement, empowerment, and social protection for all HEs. Communication on climate change and health risks is a primary impetus and focus of this component. Key activities include: (i) leveraging community health workers (CHWs) to drive public health emergency protection awareness and behaviors among communities; (ii) developing gender sensitive public health risk communications with appropriate media including mass media (TV and radio) and community level platforms (village meetings, school health clubs, and so forth); (iii) developing a national climate and health adaptation plan with the community; (iv) assessment of health system performance during climate shocks; and (v) execution of climate shock response simulation exercises. 24. Component 3: Project Management (US$5.0 million). This component will ensure efficient and effective management and implementation of the project by the Rwanda Biomedical Centre (RBC). It will finance: (i) strengthening project monitoring and evaluation (M&E); (ii) providing need-based TA and facilitating data-based cross-border learning initiatives, and the learning agenda in collaboration with WHO, IGAD and ECSA-HC; and (iii) supporting other aspects of project management such as recruitment of staff, procurement, financial management, environmental and social risk 8 MNCH defined under the Women Children Adolescent Health Strategy which includes services for the wellbeing of these population. Page 17 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) management, and reporting under the project through the provision of technical advisory services, training, operating costs, and acquisition of goods. 25. Component 4: Contingent Emergency Response (CERC) (US$0). This component will facilitate access to rapid financing by allowing for the reallocation of uncommitted project funds in the event of a natural disaster in a country, either by a formal declaration of a national emergency or upon a formal request from the government. Following an eligible crisis or emergency, the government may request that the World Bank reallocates project funds to support emergency response and reconstruction. A CERC Manual, a CERC ESMF and an Emergency Action Plan acceptable to the World Bank, will be prepared and constitute a disbursement condition for this component. C. Project Beneficiaries 26. This project is of national scope and will benefit the 14 million inhabitants of the country. It will also directly benefit about 100,000 people who are expected to cross the borders from the neighboring countries. In particular, the project will benefit women of reproductive age, including adolescents and children and people with NCDs. In addition, the beneficiaries also include livestock farmers and the general population, who benefit from less exposure to a disease which can be transmitted to humans from animals, condition known as zoonoses. Finally, all new and existing health workers and staff of public health, veterinary services and laboratories involved in health emergencies preparedness and response will benefit from the training and continuous support. D. Rationale for Bank Involvement and Role of Partners 27. The project will enable extensive technical coordination between relevant government institutions and public and private development partners. The One Health Committee 9 will become a One Health Multisectoral Coordination Mechanism, set up, with the involvement of external specialists, to provide domain-specific guidance around focus areas like communicable diseases surveillance and diagnostics, the antimicrobial resistance testing, health workforce skilling, community engagement platforms and so forth. The country will benefit from support from the regional entities ECSA- HC and IGAD under the MPA, as well as from advanced peer-to-peer learning opportunities available to all countries participating in the HEPRR MPA. In addition, the project will build upon existing public–private partnerships such as with the University of Wisconsin – Madison Global Health Institute and Abbott Labs, among others, and establish strategic partnerships with United Nations agencies and other development partners based in Rwanda to align activities with global health security norms, standards and best practices, alert threshold setting, and data gathering, among others. E. Lessons Learned 28. No lessons learned have yet been drawn from Phase 1 of the MPA as it is in its first few months of implementation. However, the COVID-19 pandemic, natural disasters, and other emergencies that have exacerbated health system challenges have taught us important lessons in the response to HEs, such as: the need for multisectoral collaboration fostering a multidisciplinary engagement and building on existing national capacity and partnerships are crucial components to achieve efficient results; the need to implement the One Health principles and reach regional collaboration for a more effective response to pandemics; and the value of informing, communicating, and educating the population so that people are responsive and adopt the necessary behaviors to constrain HEs. 9 Existing structure as described in the One Health Policy dated March 2021. Page 18 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 29. RBC as the implementer will have overall responsibility for the oversight, coordination, management, and supervision of all components of the project by providing leadership and guidance. Five more institutions will support implementation activities with technical oversight, namely: Rwanda Agriculture and Animal Resources Development Board, for animal health surveillance and response to zoonotic diseases; Rwanda Development Board (RDB) for wildlife surveillance and environmental activities; Rwanda Environment Management Authority, to facilitate coordination and oversight of the implementation of national environmental policy; Gender Monitoring office (GMO), to ensure gender aspects of HE are well addressed at all levels of the project implementation; and the National Child Development Agency (NCDA), for integrated early childhood development (ECD) service delivery. An inter-ministerial and inter-agency One Health Multisectoral Coordination Mechanism with representatives from Ministries of Finance, Health, Agriculture, Environment, and other social and economic clusters institutions will serve as the apex governance body for providing high-level oversight, steering and policy direction to the project. This will enable holistic guidance aligned to national health priorities while also assessing complex issues, trade-offs and interlinkages across the human health, livestock, wildlife, and environment domains. The project implementation arrangements will be described in detail in the Project Implementation Manual (PIM). 30. Rwanda will be part of the Regional Advisory Committee (RAC) that will serve as the bridge between the MPA and the overall regional agenda and priorities. The RAC will consist of representatives of all participating countries and regional bodies that support project implementation, as well as global experts, representatives of the International Development Association, and other entities, to be described in the PIM. The RAC will provide a forum for broader technical and regional engagement beyond the MPA's focus, with emphasis on ensuring program alignment with the broader regional agenda and strategic direction. B. Results Monitoring and Evaluation Arrangements 31. The project’s results framework includes both PDO-level and intermediate results indicators that follow the indicators proposed under the MPA. Indicators have been judiciously selected and added to assess the effectiveness and impact of project interventions. They contribute to the Scorecard indicators of Healthier Lives with the 14 million people benefitting from strengthened capacity to prevent, detect, and respond to health emergencies. The single project implementation unit (SPIU) will be responsible for: (i) compiling data; (ii) monitoring and tracking results and to propose course corrections; and (iii) reporting results to the One Health Multisectoral Coordination Mechanism, Prime Ministers’ offices and to the World Bank. Further, independent external program evaluations by select partner institutes will promote cross-learning, protocol optimization and uptake acceleration based on user feedback, technology acceptance levels and impact metrics across target communities and cohorts intended to benefit and contribute toward the program. The emphasis on continual technical coordination between on-ground executors and guidance from specialized collaborators is designed to maximize suitability, receptivity and efficacy of the public health security initiatives being rolled out. C. Sustainability 32. All the proposed interventions are designed to have a lasting impact. The project's design is premised on the need to ensure sustainability and maximize the impact of limited resources by combining a focus on traditional HE preparedness and response with core elements of health systems strengthening (HSS). Project interventions have been Page 19 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) designed to align with global standards for pandemic preparedness and response, including a selection of interventions that link directly to the WHO Joint External Evaluation (JEE) technical areas, which strengthen national capacities in 19 technical areas including gender in preparedness response. In addition to being closely aligned with the country’s Five- Year National Action Plan for Health Security and the NHEROP, the proposed interventions will bolster the country’s systems and capacities to sustainably prepare, prevent, detect, and respond to disease outbreaks. In HSS, the focus on training and capacity (especially laboratories), and the quality of health services, including maternal and child health and nutrition services, will enhance the sustainability of the project. D. Alignment with Corporate Commitments 33. Climate change and climate shocks are among the core public health emergencies that the MPA addresses; building climate change resilience and preparedness are fundamental program activities. Refer to Annex 2 for a summary of the project’s Climate Disaster Risk Screening, Climate Vulnerability Context, and Climate Financing. 34. Data. The project will maximize the use of available data and will collect additional data only to fill any gaps as required to implement activities under Component 2. No personal data will be managed by the World Bank. When gathering personal data, prior consent will be secured from the participants. Data collection will be carried out in accordance with local laws and international human rights conventions and covenants, respecting cultural sensitivities, such as: differences in culture, local behaviors and norms, religious beliefs and practices, sexual orientation, gender roles, disability, age and ethnicity and other social differences. The sourced data will be classified accordingly to ensure there is no misuse or misinterpretation of the data. Data collected under the project will be processed only for the purposes defined in the project and will be held in the Development Data Hub which is the World Bank’s official one-stop shop for the latest development data procured, acquired or used by the World Bank in accordance with the World Bank Procedure for Development Dataset Acquisition, Archiving and Dissemination. Where needed, the Development Data Hub will serve as a data storage repository, providing secure and managed, long-term storage for the gathered data. Rwanda already has in place a data protection law for the protection of personal data and to ensure privacy of individuals. This is Law No 058/2021 of 13/10/2021 10 officially gazetted on October 15, 2021, which is the World Bank’s official resource of reference for the latest development data procured, acquired, or used by the World Bank in accordance with the World Bank Procedure for Development Dataset Acquisition, Archiving and Dissemination. 35. Citizen Engagement. The project will build on the MPA Stakeholder Engagement Plan (SEP) and align with activities of subcomponent 2.3 of the project to engage communities in all stages of project cycle by sanctioning continuous engagement, information dissemination, and feedback to ensure inclusion and last-mile connectivity. Local networks and frontline actors with knowledge and organizational capacity will promote localized readiness, through quicker reporting and data gathering, to trigger socially appropriate protective actions that expedite resilience in response to HEs. Age and gender related vulnerabilities will be addressed as a matter of the highest priority. Continuous engagement will be found on IGAD-linked 11 country-specific websites with an online feedback feature that will enable readers to leave comments. Although newspaper columns will be the basic information sharing tool, information will also be disclosed through dedicated radio and television channels and the above-mentioned websites, taking into consideration special accessibility needs of citizens who have disabilities or are unable to read. Consultation will form a part of the preparation phase; later, beneficiary satisfaction surveys will be deployed twice (Mid-term Review [MTR] and implementation completion report review stages) to seek citizen feedback during the project's lifetime (under the indicator Percentage of beneficiaries who are satisfied with project activities). 10 Rwanda’s law on the protection of personal data and privacy (DPP Law). Data Protection Office. Republic of Rwanda - https://dpo.gov.rw/dpp- law/ 11 IGAD Resilience Portal. https://resilience.igad.int Page 20 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) 36. Paris Alignment. The operation is aligned with the adaptation and mitigation goals of the Paris Agreement. It focuses on activities aimed at strengthening resilience of the health system. Subcomponents 1.1 and 1.3 will include construction, while subcomponent 2.1 will include building rehabilitation. Construction and rehabilitation will include climate resiliency measures, with a focus on resilience to floods, landslides, and high heat. Under subcomponent 2.2, the project will support the transfer system for MCH emergencies, NCDs cases and suspected cases of pandemic-prone disease—this activity may be exposed to Rwanda’s climate shocks. Climate-sensitive planning will therefore be integrated to reduce any such impact. Subcomponent 2.3 will support risk communication and community engagement through leveraging CHWs to enhance community emergency protection awareness. A module on the climate vulnerability of Rwanda, climate, and health links (including impacts on climate-sensitive diseases) and climate emergency preparedness and response will be included in the training material for CHWs. The project is expected to have only limited activities that are vulnerable to Rwanda’s climatic hazards (intense rainfall, heatwaves, extreme floods, landslides). 37. Adaptation and mitigation risk reduction measures. Most project activities are universally aligned for climate change mitigation and do not contribute to GHG emissions. Building construction under subcomponents 1.1 and 1.3, and rehabilitation under subcomponent 2.1, will meet EDGE 12 energy efficiency standards; the project will hire a consultant to support meeting these standards and at least a 20 percent reduction in energy use. 38. Gender. In line with the overall PAD for the HEPRR MPA, the Rwanda HEPRR project fulfils the gender-related corporate requirements. The project will focus on two key areas by addressing: (a) gender disparities in the health workforce by supporting the recently launched a 4 x 4 strategy that seeks to quadruple the number of health workers in four years closing gender gaps among health care workers. The project will encourage women to participate in STEM training for HE by: establishing a training program in computational diagnostics—with as equitable a sex ratio in trainees as is feasible; and training additional field epidemiologists, data scientists, and laboratory professionals with a focus on gender equity in training and subsequent employment in these fields as feasible; and, (b) gender gaps in essential services, addressed by ensuring inclusion of essential Reproductive Maternal Neonatal Child Adolescent Health supplies and services as part of the essential services package and maintenance of adequate Reproductive Maternal Neonatal Child Adolescent care during HEs. Activities to fulfill these two areas are described in the subcomponents 1.2 and 2.2 respectively. Gender-specific intermediate indicators to measure closing these gaps have been included in the results framework of the project (for example of two indicators: Percentage of female professionals with specialized training for delivering health security functions including the One Health approach at the national and intermediate levels; and Percentage of pregnant women receiving four antenatal care visits). IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis (i) Technical 39. The design of the HEPRR Program was guided by global evidence showing that simultaneous investments in pandemic preparedness response are critical for countries to build ‘emergency-ready health systems’, which will improve health security and safeguard the lives and livelihoods of the entire region’s population, including Rwanda. The technical design of the HEPRR Rwanda project introduces the One Health agenda to strengthens links between human, animal, and environmental health ensuring engagement at all levels in the human–animal–environment health continuum. Additionally, this project’s design includes support on preparedness and excellence to the surveillance, laboratory and human resources that will further improve the readiness, ability to respond and resilience interventions. 12 Excellence in Design for Greater Efficiencies Page 21 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Furthermore, this design will build strength in the health system on the provision of essential health services that underpin preparedness, protecting the population against HEs and climate shocks. (ii) Economic 40. In the case of Rwanda, a cost-benefit analysis was conducted to estimate the project’s economic return on investment. Under the base-case scenario of a 3 percent discount rate, the project is estimated to yield a benefit-cost ratio of 1.83, suggesting that for every US$1 invested, the project will yield an economic return of US$1.83. Over the five years of project implementation, the net economic benefits generated by the projects’ inputs would result in a positive net present value (NPV) of US$61.12 million. The estimated benefit is based on the potential impact of investing in preparedness, prevention, and resilience on mortality and morbidity only, also considering the prevention of potential losses if essential health provision of services is discontinued or scarcely provided. It also includes the loss due to lost work time due to disease and the loss due to mental health effects of pandemic effects. It does not include the potential impact of a pandemic on the economy due to restricted mobilities and a slowdown of commercial business (Annex 2). B. Fiduciary (i) Financial Management (FM) 41. The FM assessment was carried out for the project in accordance with the World Bank Policy and Directives on Investment Project Financing (IPF). The assessment was carried out on the lead implementing entity, RBC, to determine whether it has acceptable FM arrangements, which will ensure that: (i) funds are used for the intended purposes in an effective, efficient, and economical way; (ii) financial reports will be prepared in a reliable, accurate, and timely manner; and (iii) project assets will be appropriately safeguarded. Based on this assessment, the FM risk for the project is rated Moderate. Key risks identified for this project are: (i) inadequate preparation of an Annual Work Plan and Budget (AWPB) which could lead to irregularities in spending and accountability of resources; (ii) lack of evidence to verify internal and external audit review by the audit committee; and (iii) delayed action on internal control gaps noted on audit reports. These will be mitigated by placing adequate staff in the SPIU; and capacity building and training on the World Bank- financed operations and using internal audit functions and follow-up of audit committees for timely action on audit report findings. An action plan has been prepared to help mitigate these risks and which will be monitored throughout implementation. 42. The FM arrangement of the project will be the following. An AWPB will be prepared for each of the components with the detail of the credit resources and that will be submitted to the World Bank for approval. The SPIU at RBC will be adequately staffed and will receive training on managing the World Bank-financed projects. RBC will have its own designated account and will implement the project with technical input from other implementers; it will submit quarterly financial reports and annual audit reports to the World Bank. The internal audit units of RBC will audit the project and make their reports available to the World Bank as required. RBC will be responsible for taking timely action on the audit report findings and for notifying the World Bank. Detailed FM arrangements will be captured as part of the PIM. (ii) Procurement 43. Procurement will be carried out in accordance with the World Bank Procurement Regulations for IPF Borrowers (Borrowers Regulations), dated September 2023; the Guidelines on Preventing and Combating Fraud and Corruption in projects financed by IBRD Loans and IDA Credits and Grants, revised July 1, 2016; beneficiary disclosure arrangements, and the provisions stipulated in the Financing Agreement. The Procurement Plan, as agreed between the World Bank and the Recipient, specifies procurement methods and their applicable thresholds, and activities subject to the World Bank review. Once effective, the implementing agency shall submit the Procurement Plan through the Systematic Tracking of Exchanges in Procurement (STEP), and it will be disclosed to the public. The Project Procurement Strategy for Page 22 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Development sets out the selection methods to be followed by the Recipient during project implementation in the procurement of goods, works, non-consulting and consulting services financed by the World Bank. The Procurement Plan will be updated annually. Rated Criteria will be used for all international competitive procurements, with the exception of procurement of pharmaceuticals, vaccines, off-the-shelf goods and educational materials, commodities and other exceptions cleared by the World Bank on a fit-for-purpose basis, where use of Rated Criteria is not mandatory. 44. Based on risks and gaps identified, the project procurement risk rating is Moderate. The concept stage Procurement Risk Assessment and Management System (PRAMS) with the Moderate procurement performance was validated during the appraisal, with the following key risks identified: (i) likelihood of occurrence of corruption, collusion, and conflicts of interest; (ii) contract price increase due to inflation, currency instability, and interest rates; (iii) unexpected extreme weather, intense rainfall, that can affect project timelines; and (iv) limited skills in the World Bank’s procurement framework. SPIU has five procurement staff implementing more than 20 projects, but only one, the head of procurement, is familiar with the World Bank’s procurement framework. The recommended mitigation measures are: (i) improve the complaint management system, strengthen internal and external audits, and disclosure of information and procurement data to the public; (ii) make sure provision for price adjustment is included in contract documents; and, (iii) conduct training in the World Bank’s procurement framework. Additionally, a dedicated procurement specialist is expected for the project. C. Legal Operational Policies @#&OPS~Doctype~OPS^dynamics@padlegalpolicy#doctemplate Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Area OP 7.60 No D. Environmental and Social 45. The environmental risks are related to medical supplies, waste management associated with health care, and hazardous waste handling, disposal and transfer, correlated to occupational health and safety for project workers, and health care workers at hospitals or health care facilities addressed under Environmental and Social Standards 2 (ESS2), community health and safety risks (addressed under ESS4), and limited pollution risk (addressed under ESS3). Risk and impacts related to the civil works— including health and safety risks for workers and communities, construction waste management, and within-facility air pollution—are expected to be site-specific, reversible, and of low magnitude that can be mitigated following appropriate measures. The social risks under ESS1 pertain to social exclusion of vulnerable groups from access to project benefits (for example, persons with disabilities, the elderly, women headed households and widows, children without parents and so forth). To mitigate the project risks, the implemeting agencies, namely RBC, will develop an Enviromental and Social (E&S) screening template, as part of the project Environmental and Social Management Framework (ESMP). Every implementing agency will use that framework to assess the E&S risks of their respective project activities, and identify proportionate mitigation measures in the form of activity-specific E&S management measures (that is, ESMP checklist, or environmental, social health and safety mitigation measures/clauses to be included in the bidding documents, templates for mitigation measures, and other E&S mitigation tools). The project's E&S risks and mitigation measures are included in its Environmental and Social Management Framework (ESMF) that will be prepared, consulted, disclosed and will be adopted not later than three months after the Effectiveness Date Page 23 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) and shall thereafter be implemented throughout project implementation. The Environment and Social Commitment Plan (ESCP) was published on April 29, 2024. 13The project’s ESMF will include, among other aspects, a Medical Waste Management Plan (MWMP) to address relevant identified risks under the project. The MWMP will be prepared by RBC in accordance with Rwanda’s regulations, and consistent with ESS3, and relevant the World Bank Group’s Environmental, Health and Safety Guidelines (World Bank Group EHS Guidelines). The MWMP will be prepared as part of the project ESMF which will be reviewed and cleared by the World Bank and disclosed prior to implementation of relevant activities. Risks of social exclusion and sexual exploitation and abuse or sexual harrassment (SEA/SH) will be addressed, as appropriate, in the design of project activities and through relevant mitigation measures included in the E&S documentation prepared during implementation including the project ESMF, Code of Conduct for workers, and through availability of effective stakeholder engagement and grievance redress mechanisms (GRM). V. GRIEVANCE REDRESS SERVICES 46. Grievance Redress. Communities and individuals who believe that they are adversely affected by a project supported by the World Bank may submit complaints to existing project-level grievance mechanisms or the World Bank’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. The project-affected communities and individuals may submit their complaint to the World Bank’s independent Accountability Mechanism. The AM houses the Inspection Panel, which determines whether harm occurred, or could occur, as a result of World Bank noncompliance with its policies and procedures, and the Dispute Resolution Service, which provides communities and borrowers with the opportunity to address complaints through dispute resolution. Complaints may be submitted to the AM at any time after concerns have been brought directly to the attention of World Bank Management and after Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s Grievance Redress Service (GRS), visit http://www.worldbank.org/GRS. For information on how to submit complaints to the World Bank’s Accountability Mechanism, visit https://accountability.worldbank.org. VI. KEY RISKS 47. Overall risk for the project in Rwanda is Substantial. The risks associated with technical design, institutional capacity for implementation and sustainability, stakeholders, and environmental and social factors are all rated Substantial. The overall program risk remains substantial because of the fragile contexts and limited institutional capacities in several countries in AFE seeking to join the MPA; the post-COVID-19 socio-economic recovery challenges and uncertainties; the program’s complexity and multisectoral dimensions; and the community health, safety, and occupational risks from proposed project activities. 48. Technical design of the project risk is Substantial. The project will support investments in health systems and in approaches to HE preparedness and response that are complex and will require significant coordination and political will to maximize benefits at both the country and regional levels. Furthermore, the project requires multisectoral and intersectoral collaboration to achieve the PDO. This approach deviates from the standard practice of a siloed sectoral focus, which then presents some unique coordination challenges. These risks are mitigated by capacitating strong conveners at the national level, capable of bringing sectors together to forge a consensus on sectoral and multisectoral priorities and approaches for implementation of interventions. The residual risk, however, remains substantial even after 13 https://rbc.gov.rw/fileadmin/user_upload/report_2024/Annex_8_-_Environmental_and_Social_Commitment_Plan__ESCP__HERRP_P- 504764_NEGOCIATED.pdf Page 24 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) mitigation measures because of the complexity and ambition of the project, which will require dedicated hands-on support to sectors, and implementing bodies, to achieve the PDO of the project. 49. Institutional capacity for implementation and sustainability risk is Substantial. RBC, as the lead implementing agency, has substantial experience and expertise in planning and delivering interventions, including HEs and pandemic preparedness and response. Despite that experience, its capacity to manage a complex, multi-level and multisectoral project of this nature represents an additional challenge. Risk mitigation measures will include capacity building during project implementation and additional support within RBC as well as consolidation of existing policies and laws supporting the Emergency Response in the country. 50. Environmental and social risks are rated Substantial. Rwanda is experiencing an increasing trend of climate-induced loss and damage, most recently from landslides and flooding in May 2023. Such events can result in HEs that snowball into severe and large-scale environmental degradation. To address risks related to the Biosafety Level-3 laboratory in the Diagnostics Development and Research Center, appropriate instruments will be prepared and implemented, guided by the project’s ESMF, stipulating material measures to safeguard against exposure and other Environmental, Health and Safety risks. Overall, the ESMF will guide the project’s team in the preparation of the necessary Environmental and Social risk management instruments for each subproject, to comply with the relevant Rwanda laws and the World Bank’s ESS under the Environmental and Social Framework (ESF). According to the World Bank Environmental and Social Framework, seven of the 10 are ESSs relevant to the project (ESS1, ESS2, ESS3, ESS4, ESS6, ESS8 and ESS10). 51. Stakeholders' risk is rated Substantial. There is a risk of inefficiency, duplication, and possible exclusion, especially of vulnerable and disadvantaged groups. To mitigate the inherent risk, the HEPRR project will ensure that RBC is responsible for coordinating all the technical activities under the HEPRR Program. RBC will facilitate consistent engagement of all the key stakeholders. Additionally, at the country level, national platforms or coordinating bodies—at the highest level of government, such as the Ministry of Health (MoH)—will help coordinate actions across the different program implementers. The project will be encouraged to ensure civil society engagement, including opportunities for the voice and representation of the private sector. The results framework also includes indicators to measure and track the level of citizen engagement in the project. Page 25 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) VII. RESULTS FRAMEWORK AND MONITORING @#&OPS~Doctype~OPS^dynamics@padannexresultframework#doctemplate PDO Indicators by PDO Outcomes Baseline Period 1 Closing Period Strengthen health system resilience and multisectoral preparedness and response to health emergencies in the Republic of Rwanda The average score of 3.5 in at least 3 JEE core capacity area in the Prevent axis. (Number) Feb/2024 Mar/2027 Mar/2030 2.5 3.0 3.5 The average score of 3.5 in at least 3 JEE core capacity areas in Detect axis. (Number) Feb/2024 Mar/2027 Mar/2030 1.5 3.0 3.5 The average score of 3.5 in at least 3 JEE core capacity areas in Respond axis (Number) Jan/2024 Mar/2027 Mar/2030 2.5 3.0 3.5 The detected health events, where the country met the 7-1-7 targets (Percentage) Feb/2024 Mar/2027 Mar/2030 70 80 95 Project-supported laboratories that have achieved a 3-star rating or higher during a Stepwise Laboratory Improvement Process (SLIPTA) audit (Percentage) Feb/2024 Mar/2027 Mar/2030 30 60 90 Intermediate Indicators by Components Baseline Period 1 Closing Period Component 1: Strengthening the Preparedness and Resilience of the Health System to manage HEs Professionals with specialized training for delivering health security functions including the One Health approach at the national and intermediate levels (Percentage) Feb/2024 Mar/2027 Mar/2030 10 40 70 Page 26 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Female professionals with specialized training for delivering health security functions including the One Health approach at the national and intermediate levels (Percentage) Feb/2024 Mar/2027 Mar/2030 0 20 30 Laboratories that have mandatory licensing in line with basic quality requirements of national laboratory standards (Percentage) Feb/2024 Mar/2027 Mar/2030 10 15 50 A national multisectoral costed plan for One Health that is developed/updated and under implementation (Number) Feb/2024 Mar/2027 Mar/2030 0 1 1 Component 2: Improving early detection of and response to HEs through a multisectoral approach Health facilities with risk assessments for climate shocks conducted in project coverage area (Climate indicator) (Percentage) Feb/2024 Mar/2027 Mar/2030 0 30 80 Pregnant women receiving four antenatal care visits (Percentage) Feb/2024 Mar/2027 Mar/2030 0 0 0 Health centers with a referral strategy in place (Percentage) Feb/2024 Feb/2027 Mar/2030 5 40 70 Infants receiving Pentavalent 3 vaccine (Percentage) Feb/2024 Mar/2027 Mar/2030 60 70 85 The joint field missions between national laboratory of public health and the national veterinary laboratory to collect and analyze samples related to zoonotic diseases (Number) Feb/2024 Mar/2027 Mar/2030 0 4 6 Component 3: Project Management Beneficiaries who are satisfied with project activities (Percentage) Feb/2024 Mar/2027 Mar/2030 0 70 80 Women beneficiaries who are satisfied with project activities (Percentage) Feb/2024 Mar/2024 Mar/2030 0 70 80 Component 4: Contingent Emergency Response Page 27 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Monitoring & Evaluation Plan: PDO Indicators by PDO Outcomes Strengthen health system resilience and multisectoral preparedness and response to health emergencies in the Republic of Rwanda The average score of 3.5 in at least 3 JEE core capacity areas in Prevent axis. (Number) Description The score is calculated by choosing 3 technical areas with highest scores in prevent axis and averaging the score Frequency Project reporting will be done annually. JEE assessment will be conducted once before country project close. Data source JEE Methodology for Data JEE Methodology (3rd edition). Collection Responsibility for Data Government is responsible for organizing and executing the JEE assessment, and for reporting results. Collection The average score of 3.5 in at least 3 JEE core capacity areas in Detect axis. (Number) Description The score is calculated by choosing 3 technical areas with highest scores in detect axis and averaging the score. Frequency Project reporting will be done annually. JEE assessment will be conducted once before country project close. Data source JEE Methodology for Data JEE Methodology (3rd edition). Collection Responsibility for Data Government is responsible for organizing and executing the JEE assessment, and for reporting results. Collection The average score of 3.5 in at least 3 JEE core capacity areas in Respond axis (Number) Description The score is calculated by choosing 3 technical areas with highest scores in respond axis and averaging the score. Frequency Project reporting will be done annually. JEE assessment will be conducted once before country project close. Data source JEE Methodology for Data JEE Methodology (3rd edition). Collection Responsibility for Data Government is responsible for organizing and executing the JEE assessment, and for reporting results. Collection The detected health events, where the country met the 7-1-7 targets (Percentage) Among all health events (i.e. confirmed signals that require a public health response) that were detected in the 12 Description months prior to reporting, 60% met all three of the following: detected within 7 days, notified within 1 day, and Page 28 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) responded to within 7 days. Frequency Every year. Data source The administrative records maintained by the government PLUS third-party verification. Government maintains documentation of detected outbreaks and the timing of detection, notification, and response. Methodology for Data This can include clinical records, correspondence, or other documentary evidence. A third-party monitor then confirms Collection the veracity of the documentation. Responsibility for Data Government maintains documentation. Third-party monitor performs verification. Collection Project-supported laboratories that have achieved a 3-star rating or higher during a SLIPTA audit (Percentage) Laboratories were supported through project funds. All project-supported laboratories underwent a SLIPTA audit based Description on the WHO/AFRO Methodology; 90% of project-supported laboratories scored a 3-star rating or higher in the SLIPTA audit. Frequency Annually; and SLIPTA assessment will be conducted before country project close. Data source SLIPTA audit. Methodology for Data SLIPTA methodology according to WHO/AFRO. Collection Responsibility for Data Government is responsible for organizing and executing the SLIPTA assessment, and for reporting results. Collection Monitoring & Evaluation Plan: Intermediate Results Indicators by Components Component 1: Strengthening the Preparedness and Resilience of Health Systems to manage HEs Professionals with specialized training for delivering health security functions including the One Health approach at the national and intermediate levels (Percentage) Professionals that have completed any of the specialized training within the program and allocated to the national and Description intermediate levels of Health Emergency response. Frequency Every year. Data source The project report based on the government data set. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining records of personnel. Collection Female professionals with specialized training for delivering health security functions including the One Health approach at the national and intermediate levels (Percentage) Description Professional women that have completed any of the specialized training within the program and allocated to the national Page 29 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) and intermediate levels of Health Emergency response. Frequency Every year. Data source The project report based on the government data set. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining records of personnel. Collection Laboratories that have mandatory licensing in line with basic quality requirements of national laboratory standards (Percentage) Description Laboratories that have fulfilled the mandatory licensing requirements. Frequency Every year. Data source The project report based on the government information system. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining records of the licensing status of laboratories. Collection A national multisectoral costed plan for One Health that is developed/updated and under implementation (Number) Description A fully developed national multisectoral plan with the corresponding costing and plan of action is prepared Frequency Once and then annual updates. Data source The project records, government administrative data and the information system in place. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for ensuring that the plan is updated. Collection Component 2: Improving early detection of and response to HEs through a multisectoral approach Health facilities with risk assessments for climate shocks conducted in project coverage area (Climate indicator) (Percentage) The denominator is the total number of health facilities in the project coverage areas (at the borders); the numerator is Description the number of health facilities with risks assessments for climate shocks. Frequency Every year. Data source The project report based on the government data set. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining records of the assessments. Collection Pregnant women receiving four antenatal care visits (Percentage) Description Number of women with four antenatal care visits out of the total number of women registered for prenatal care. Frequency Every year. Page 30 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Data source The government administrative data. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining the administrative records. Collection Health centers with a referral strategy in place (Percentage) Number of Health centers with a health emergency and transfer referral strategy in place out of the total of health Description centers at the borders that are part of the project. Frequency Every year. Data source The project report based on the government data. Methodology for Data Administrative system collecting the information and reporting each year. The World Bank verification of the data. Collection Responsibility for Data The government is responsible for maintaining the administrative records. Collection Infants receiving Pentavalent 3 vaccine (Percentage) Total number of children under one year of age that have been vaccinated with the pentavalent vaccine over the total Description number of children under one year of age as reported in the birth certificate emission. Frequency Every year. Data source The national Health Information System. Methodology for Data The indicator measures the number of fully immunized children. Administrative system collecting the information and Collection reporting each year. The World Bank verification of the data. Responsibility for Data The government is responsible for maintaining the administrative records. Collection The joint field missions between national laboratory of public health and the national veterinary laboratory to collect and analyze samples related to zoonotic diseases (Number) Joint field missions between national laboratory of public health and the national veterinary laboratory carried out to Description collect and analyze samples related to zoonotic diseases. Frequency Every year. Data source The project technical unit. Methodology for Data The indicator measures the number of field missions between national laboratory of public health and the national Collection veterinary laboratory carried out to collect and analyze samples related to zoonotic diseases. Responsibility for Data The project technical unit. Collection Component 3: Project Management Beneficiaries who are satisfied with project activities (Percentage) Description The level of satisfaction of the various beneficiaries of the project is collected. Page 31 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Frequency Twice during the lifecyle of the project: MTR and end of the project. Data source The government report. Methodology for Data A mechanism to collect the level of satisfaction of the various beneficiaries of the project is implemented. Collection Responsibility for Data The project technical unit. Collection Women beneficiaries who are satisfied with project activities (Percentage) Description The level of satisfaction of the beneficiaries of the project, who are female, is collected. Frequency Twice during the lifecycle of the project: MTR and end of the project. Data source The government report. Methodology for Data A mechanism to collect the level of satisifaction of the various beneficiaries of the project, disaggregated by gender, is Collection implemented. Responsibility for Data The project technical unit. Collection Component 4: Contingent Emergency Response Page 32 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) ANNEX 1: Implementation Arrangements and Support Plan Financial management 1. Planning and budgeting. RBC shall follow the government’s planning and budgeting procedures. The project budgets shall also be presented to the One Health Multisectoral Coordination Mechanism for approval and included in the overall Country budgets approved by Parliament. The approved budgets will be monitored on a monthly and quarterly basis by the preparation and analysis of budget execution reports including: (a) budget for the period and for the year; (b) actual expenditure for the period and to date; (c) future expenditure commitments; and (d) balance of period budget remaining (actual expenditure and commitments together compared to period budget). The consolidated annual workplan and budget that clearly show planned activities under each component and implementing entity shall be submitted to the World Bank for no-objection. Table 1.1 shows the Financial Management Plan (FM) action plan. 2. Accounting and staffing. RBC uses the Integrated Financial Management Information System to record their transactions. There is a well-established SPIU at RBC. There will be a comprehensive start-up workshop where all implementing entities will be sensitized on FM requirements for the project to build on capacity on managing the World Bank-financed operations. Regular training will thereafter be provided for continuous improvement during project implementation. 3. Internal control and internal audit. All implementing entities are governed by the legal frameworks and manuals of the government. The project involves financing from credit and has multiple components and subcomponents which will involve specific arrangements such as CERC. Therefore, RBC shall develop a PIM that will reflect the FM arrangements under this project, covering all the implementing agencies and arrangements under each of the components. The PIM will reflect detailed internal control arrangements for the project, including the extent of segregation of functions in payment processing and internal check mechanisms, in addition to payment approval and authorization arrangements. To enhance internal control arrangements for the project, the internal audit unit will review project activity, in accordance with the Annual Risk Assessment and Internal Audit Plan and submit reports to the project management team and to the World Bank during implementation support missions. The audit committee should also follow up on the implementation of audit recommendations. 4. Financial reporting. RBC will prepare and submit quarterly interim financial reports (IFRs) to the World Bank within 45 days after the end of the quarter end. The interim financial reports will be used to monitor project financial progress, including the rate of budget execution and level of disbursements. Financial reports for the project shall at a minimum include sources and uses of funds (revenues and expenditures statement); financial position statement; cash flow statement; budget execution report; cash forecast; designated account activity statement for each designated account; and notes on accounting policies and appendices. Experience from other projects implemented by the entities noted reporting quality gaps. Training will be provided to avoid such risks in this project. 5. External audit. Based on experience from other projects implemented by RBC, audit reports were submitted on time with unqualified (clean) audit opinions on the financial statement and compliance with laws and regulations and guidelines, with improvements recommended on realizing value for money under the COVID-19 emergency project. The reports also revealed weaknesses in internal control with gaps in management of assets, procurement, and delay in Page 33 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) project implementation. Follow-up on the audit findings also needs to be strengthened. 1 The project shall be subject to external audit by the Office of the Auditor General (OAG) who has been auditing other World Bank-funded projects implemented by the Government of Rwanda. Should the OAG seek to outsource the audit, the firm must be acceptable to the IDA. The audit reports and management letters will be submitted to the World Bank within six months after the end of the financial year. The audit reports will be publicly disclosed in accordance with the World Bank Access to Information Policy. Upon receipt of the audit reports, RBC will be expected to prepare an action plan to address the audit findings. 6. Funds flow arrangements. The project will maintain one segregated designated account for RBC, which shall be maintained at the National Bank of Rwanda and shall be denominated in US dollars. It will also maintain a Project Account at National Bank of Rwanda denominated in Rwanda francs for any transfer that may be needed from the DA. Disbursements will follow the report-based disbursement method whereby advances will be made based on two quarter forecasts to be prepared by the implementing entities. The project may also use direct payments, advances to the DA, reimbursement and special commitments depending on the case. Upon effectiveness, the project will submit to the World Bank a request for withdrawal of funds based on the initial six-month expenditure forecast. The detailed modalities will be presented in the PIM and the Disbursement and Financial Information Letter. The project has a CERC component too, and the most effective funds flow mechanism for CERC activities would be assessed and determined should this component be activated. Table 1.1. FM Action Plan No. Action Timeline Responsibility 1 Prepare AWPB with clarity on components, Not later than March 31 of RBC categories, and financiers each Fiscal Year 2 Prepare FM section of the PIM to detail internal Effectiveness condition RBC control processes and roles and responsibilities of entities 3 Internal audit (IA) to be conducted based on the risk As per the annual audit plan RBC assessment, and report shared with the World Bank 4 Audit committee at RBC to meet regularly and ongoing RBC supervise the implementation of audit findings 5 Provide a plan for implementation of Within a month after receipt RBC recommendations of internal and external audit of the audit report findings 1 For FY June 2023, Rwanda Stunting Prevention and Reduction Project had implemented 75% of audit recommendations; Rwanda COVID-19 Emergency Response Project implemented 50% of the recommendations. Page 34 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) ANNEX 2: Climate Change Vulnerability Context 1. The Project has been screened for short and long-term climate disasters and risks and has been found to be highly exposed, while the potential risk to project activities is low. Rwanda is a landlocked, hilly country with a tropical climate. Its four main climatic regions are the Lake Kivu region and environs, the highlands, the central plateau, and the eastern plains. The mean annual temperature of Rwanda is currently 19.1°C with monthly temperatures ranging between 18.5°C (July), and 19.5°C (September). But mean annual temperature is projected to increase by 1.9°C by the 2050s and 3.9°C by the end of the century, with increases in temperature across all seasons. These increased temperatures are likely to extend the duration of heatwaves by at least 85 days by the 2090s, while reducing cold spells. Rainfall is experienced year-round, though most significantly from September to May (annual precipitation is 1,170.2 mm). Most rainfall is received in the western Highlands (Congo-Nile Ridge and Virunga volcanic chain: 1,300 mm to 1,600 mm), around Lake Kivu (1,200 mm), and the Bugarama plains in the southwestern region (1,500 mm). 2. Over the past three decades, Rwanda has experienced more frequent droughts, and intense rainfall triggering floods and landslides, especially in the northern and western provinces, resulting in damage and losses. The eastern province has experienced more severe droughts than the rest of the country. The frequency of heavy rainfall episodes is expected to increase from nine percent to 60 percent and the intensity of rainfall events is projected to increase from three percent to 17 percent. Droughts have historically had the widest geographical reach in Rwanda. For example, the 1996 drought affected 12 percent of the population. 2 In the northern and western provinces, the rainy seasons are becoming shorter and more intense, which has heightened the risk of soil erosion in these mountainous areas. As a result, the country ranks among those most severely affected by landslides worldwide, with two events among the 15 worst landslides of all time. In 2023, landslides caused 135 deaths and, along with floods and rainstorms, damaged up to 5,963 houses, 58 schools, four health centers, 48 bridges, many national and district roads, numerous voltage lines, 12 power stations, eight water treatment plants, and 100 water supply systems. 3 3. Climate change has significant impacts on health in Rwanda. The increase in the frequency and severity of climate events such as severe droughts, heatwaves, wildfires, intense rainfall, extreme flooding, and landslides have significant direct physical impacts on the health of citizens through vector- and water-borne diseases, heat-related illnesses, noncommunicable diseases, food insecurity and malnutrition, in addition to impacts on the health system and health service delivery. Malaria is the third most prevalent cause of death and disability combined; it is also a leading cause of under-five mortality. 4 Evidence from Rwanda shows that overall, the incidence of malaria increases with precipitation and air temperature—coupled with other environmental factors such as topography, land cover, and land use (especially irrigation usage). 5 Projected increases in climate variability are expected to facilitate the spread of malaria in the 2 World Bank Group. 2022. Rwanda Country Climate and Development Report. https://openknowledge.worldbank.org/bitstream/handle/10986/38067/MainReport.pdf 3 Ministry in charge of Emergency Management (MINEMA). Disaster Effects Situation Report from 3 to 22 May 2023. https://www.minema.gov.rw/publications 4 Gupta, N., Hirschhorn, L. R., Rwabukwisi, F. C., Drobac, P., Sayinzoga, F., Mugeni, C., ... & Amoroso, C. (2018). Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy. BMC public health, 18(1), 1-9. 5 Colón-González, F. J., Tompkins, A. M., Biondi, R., Bizimana, J. P., & Namanya, D. B. (2016). Assessing the effects of air temperature and rainfall on malaria incidence: an epidemiological study across Rwanda and Uganda. Geospatial health, 11(s1). Page 35 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Rwandan highlands where malaria is non-endemic. 6 Diarrheal diseases are a major public health burden in Rwanda and are the third most prevalent cause of death among children under five years of age. 7 According to the Rwanda Demographic Health Survey (2019–20), 25.0 percent of children 12–23 months of age and 22.9 percent of children 6– 11 months of age had diarrhea during the fortnight preceding the survey. 8 Studies from Rwanda have shown a strong association between rainfall and unsafe water sources—and inadequate sanitation. Heavy rains, flooding, and landslides in early 2020, led to over 53 deaths and 84 injuries, especially in the western and northern provinces. 9 Projected increases in rainfall intensity and frequency will likely lead to more rainfall events and severe flooding, with significant implications for water-borne disease transmission (drinking water sources being contaminated by floodwater), and damage to critical infrastructure. 4. Further, climate change has a substantive negative impact on health service delivery. Frequent torrential rains, extreme floods and landslides have already caused severe damage to health facilities and other critical infrastructure including roads, bridges, and power lines. For example, heavy rains during early May 2023 caused significant damage to eight health facilities, six water treatment plants, 17 roads and 26 bridges, particularly in the northern, western and southern parts of the country, hindering health service delivery and posing risks to health workers and patients alike. 10 Similarly, heavy rains, flooding, and landslides in early 2020, lead to over 53 deaths and 84 injuries especially in the western and northern provinces. 11 5. Agriculture is highly vulnerable to climate change, which thus threatens food security and nutrition in Rwanda. 12 Increasingly unpredictable weather patterns including droughts and floods currently impact food security in the country, and this is expected to further deteriorate with climate change. 13 Research in the country shows a direct relationship between climate change and food production, and then between reduced food production and stunting. 14, 15, 16 For example, a study found that crop failure led to increased stunting in Rwandan girls; conversely, another study in the 6 Maniragaba, A., Muse, S. G., Benjamin, M. N., & Kato, N. J. (2018). Impact of Climate Variation on Malaria Incidence in Rwandan Highland. East African Journal Science, 8(8), P56-75. 7 Claudine, U., Kim, J. Y., Kim, E. M., & Yong, T. S. (2021). Association between sociodemographic factors and diarrhea in children under 5 years in Rwanda. The Korean Journal of Parasitology, 59(1), 61. 8 The 2019-20 Rwanda Demographic and Health Survey (RDHS) | National Institute of Statistics Rwanda 9 CGTN (2020, May 08) Death toll rises to 65 in Rwanda heavy rains. Death toll rises to 65 in Rwanda heavy rains - CGTN 10 IFRC (2023, August 24) Rwanda: Floods and Landslides – Operational Update (MDRRWO22). https://reliefweb.int/report/rwanda/rwanda-floods- and-landslides-operational-update-mdrrw022 11 CGTN (2020, May 08) Death toll rises to 65 in Rwanda heavy rains. Death toll rises to 65 in Rwanda heavy rains - CGTN 12 J.R. Gapusi and G. Otieno, “Climate-resilient seed systems and access and benefit sharing in Rwanda,” ISSD Africa, Thematic Working Group 3 (2017), https://cgspace.cgiar.org/bitstream/handle/10568/96095/ISSD_Rwanda_2017.pdf?sequence=1&isAllowed=y. 13 Food and Agriculture Organization (FAO), “Climate Change, Food Security, and Nutrition,” learning panel at the Global Forum on Food Security and Nutrition (2015), http://www.fao.org/fsnforum/activities/discussions/climate-change-and-fsn. 14 World Bank, Rwanda Economic Update (Washington, DC: World Bank Group, 2018), https://documents1.worldbank.org/curated/en/360651529100512847/pdf/127256-NWP-P164510-PUBLIC-Rwanda-Economic-Update-ed-no-12- June-2018.pdf. 15 Malcolm Jacob, “An Analysis of the Impacts of Climate Change on Food Security in the Albertine Rift of East Africa” (masters dissertation, International Development, Community and Environment (IDCE), Clarke University, 2021), https://commons.clarku.edu/idce_masters_papers/248. 16 Kemen G. Austin, Robert H. Beach, Daniel Lapidus, Marwa E. Salem, Naomi J. Taylor, Mads Knudsen, and Noel Ujeneza, “Impacts of Climate Change on Potential Productivity of Eleven Staple Crops in Rwanda” Sustainability 12, no. 10(2020): 4116, https://www.mdpi.com/2071- 1050/12/10/4116. Page 36 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) country found lower stunting during periods of high agricultural production. 17, 18 Further, a significant increase in the number of days with temperatures in excess of 25°C is expected to occur between October and May. Because this coincides with the rainy and planting season, it will hit crop yields, aggravating associated food insecurity and malnutrition, particularly among children, women, and the elderly. 6. The project intends to implement measures to adapt to the impacts of climate change, primarily floods. Climate shocks are a major driver of HEs in the country. Flooding comprised 47.83 percent of all natural hazards in the country between 1980 and 2020. Droughts comprised 10.87 percent, storms 4.35 percent, and landslides, which are largely flooding driven, 10.87 percent. These climate shocks are becoming more frequent and severe with climate change. In total, 73.92 percent of natural hazards are directly driven by climate change. Epidemics make up another 21.74 percent of all natural hazards. 19 Climate-sensitive diseases—increasing in intensity and severity—such as malaria, dengue, diarrhea, and cholera lie behind a large proportion of the epidemics and are the leading causes of morbidity and mortality in the country. 20, 21, 22, 23 Further, epidemic-prone climate-sensitive diseases comprise a substantial proportion 10.24 percent of the total burden of disease, with diarrheal diseases making up 5.39 percent and malaria comprising 5.85 percent. Taken together, it is conservatively estimated that shocks driven by climate change make up well above 70 percent of all HEs in the country. To address the substantial impacts that climate change has on health and the health system in the country, the project will incorporate actions to address the impact of climate change on the health system, deal with the additional burden of disease from climate-sensitive diseases and prepare for and respond to climate related HEs. Specific details of how climate change is incorporated in the project are outlined in the table below. Table 2.1 Climate Adaptation and Mitigation Component Name Climate Action Component 1: Strengthening the Preparedness and Resilience of the Health Systems to Manage HEs (US$65.6 million). Subcomponent 1.1: Multisectoral This subcomponent will finance activities to strengthen HE planning, cross-border planning, financing, financing, and governance for multisectoral cross-border resilience to HEs, and governance for improved in the context of climate-driven HEs comprising well above 70 percent of all resilience to HEs (US$0.45 million) HEs. These activities will help the country deal with the additional burden of disease from climate-sensitive diseases and the additional impacts of more frequent and intense climate shocks on the health system. Climate change will be integrated with specific materials and modules throughout 17 Richard Akresh, Philip Verwimp, and Tom Bundervoet, “Civil war, crop failure, and child stunting in Rwanda,” Economic Development and Cultural Change Vol. 59, No.4 (2011): pp. 777-810 https://www.journals.uchicago.edu/doi/epdf/10.1086/660003. 18 Revati Phalkey, Clara Aranda-Jan, Sabrina Marx, Bernhard Hofle, and Rainer Sauerborn, “Systematic review of current efforts to quantify the impacts of climate change on undernutrition,” Proceedings of the National Academy of Sciences (PNAS) 112, no. 33(2015): E4522–4529, https://www.pnas.org/doi/epdf/10.1073/pnas.1409769112. 19 World Bank. (2021) CCKP – Historical Hazards – Rwanda 20 Gupta, N., Hirschhorn, L. R., Rwabukwisi, F. C., Drobac, P., Sayinzoga, F., Mugeni, C., ... & Amoroso, C. (2018). Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy. BMC public health, 18(1), 1-9. 21 Colón-González, F. J., Tompkins, A. M., Biondi, R., Bizimana, J. P., & Namanya, D. B. (2016). Assessing the effects of air temperature and rainfall on malaria incidence: an epidemiological study across Rwanda and Uganda. Geospatial health, 11(s1). 22 Claudine, U., Kim, J. Y., Kim, E. M., & Yong, T. S. (2021). Association between sociodemographic factors and diarrhea in children under 5 years in Rwanda. The Korean Journal of Parasitology, 59(1), 61. 23 The 2019-20 Rwanda Demographic and Health Survey (RDHS) | National Institute of Statistics Rwanda Page 37 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) all of the activities within the subcomponent. Climate change is a primary driver for the following activities: • Guiding documents for the One Health implementation committee will closely outline a primary focus on climate change impacts on human and animal health, and the additional burden of disease from climate-sensitive diseases and impacts of climate shocks on the health system. Climate change and climate-sensitive diseases are a core part of the committee’s training materials. • The costed and financed national multisectoral plan for One Health will have specific components on climate-sensitive diseases and the impact of climate change on animal and human health, including zoonotic diseases. Climate change will encompass a large proportion of the costed plan. • Strengthening cross-border response will have a primary focus on response to climate shocks and outbreaks of climate-sensitive diseases. Specific materials and modules in the trainings will be included on climate-sensitive disease and the impact of climate change on health, reflecting a primary focus on climate change in this activity. Further, operational materials will have specific components on climate change and health. (adaptation) Subcomponent 1.2: Health This subcomponent aims to improve the skills and capacity of the health workforce skills development sector for diagnostics, with a strong focus on diagnostics for climate- (US$3.00 million) sensitive disease and response to outbreaks during climate shocks. These activities will help the health system respond to the extra burden of climate- sensitive diseases and changing transmission patterns due to climate change as well as climate shocks which are increasing in frequency and intensity due to climate change. The following activities have a primary focus on climate change i 24: • Developing project-based mentorship initiatives will prioritize students from climate-sensitive areas. Climate vulnerability maps will be used to identify climate-vulnerable locations. Vulnerability levels will be graded and used in application scoring to give priority to people from climate vulnerable areas. Mentorship guiding materials will include substantive modules on climate-sensitive diseases, climate shocks, and use of meteorologic data against health data. Training additional field epidemiologists will prioritize students from climate sensitive areas. Climate vulnerability maps will be used to identify climate vulnerable locations. Vulnerability levels will be graded and used in application scoring to give priority to people from climate vulnerable areas. Training materials will 24 The subcomponent will not finance construction or rehabilitation. Page 38 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) include substantive modules on climate sensitive diseases, climate shocks, and use of meteorologic data against health data. The following activities are entirely focused on and driven by the effects of climate change. They aim to improve the resilience of the health system and population to climate change in Rwanda: • The subcomponent will finance the development and execution of climate and HE preparedness and response training. This activity will be entirely focused on climate change and will include materials and modules on climate-sensitive diseases and climate change and health adaptation alongside the primary focus on climate emergency preparedness and response. • The subcomponent will also finance the development of a health workforce surge capacity system to respond to climate change. This activity will support rapid response to climate shocks. The system will include plans and mechanisms to be deployed, including housing health workers to respond to climate shocks and outbreaks of climate-sensitive diseases while maintaining service delivery throughout the country. Systems for worker safety during the shocks will also be included. Climate will also be incorporated in the following activity: • Specific modules on climate emergency preparedness, climate change adaptation, and climate-sensitive diseases will be incorporated into the gender-sensitive training program. (adaptation) Subcomponent 1.3: Building This subcomponent will support strengthening of Rwanda’s capacity to capacity for the National Health develop, produce and deploy high-quality health commodities. This capacity Institute and improving access to will allow the country to adapt to the extra burden of disease and changing quality health commodities transmission dynamics associated with climate change. (US$62.00 million) The following activity is primarily focused on and driven by climate change: • Support the Integration of a One Health Laboratory and Biobank quality management systems for testing of in-process/finished products, including development of national reference standards to manage zoonotic and climate-sensitive disease outbreaks. This will include specific mechanisms for collecting and testing climate- sensitive disease samples, as well as zoonotic diseases, whose transmission dynamics are linked to climate change. Climate- sensitive diseases are one of two primary focal areas of this activity. Page 39 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Climate change will also be integrated in the following activities: • Technical assistance on the development of a One Health Laboratory will include specific content and training modules on the testing and handling of climate-sensitive disease specimens. Development of this laboratory and the capacity will help the country deal with the increased prevalence and changing transmission dynamics of climate-sensitive diseases. • Strengthening the capacity of the National Regulatory Agencies and Regional Centers of Regulatory Excellence will include focused content to support review and approval of pharmaceuticals and diagnostics to treat and test climate-sensitive diseases (particularly malaria and diarrheal diseases) to help the country respond to changing transmission dynamics and the increased prevalence of the diseases. • The five-year road map plans of action, and strategy for the National Regulatory Agencies and Regional Centers of Regulatory Excellence will include specific content and sections on accelerating quality approvals of pharmaceuticals for climate-sensitive diseases. Data and modelling will be used to identify which climate-sensitive diseases are the priority in the context. • Technical assistance to review national laws and other applicable rules on storage, distribution, and control—to determine the adequacy of the technical, legal, and regulatory frameworks for storage of health commodities—will include specific reviews of the documents for their applicability to storage to preserve the quality and integrity of pharmaceuticals during climate shocks (primarily floods and landslides) as well as during extreme heat. (adaptation) The technical assistance will also include a dedicated focus on reviewing the frameworks to reduce greenhouse gas (GHG) emissions of pharmaceutical storage. This will focus primarily on mechanisms to reduce the use of hydrofluorocarbon refrigerants, moving to refrigerants with non-fluorinated gases as well as low GHG emissions transport options for the pharmaceutical supply chain. (mitigation) The expansion of the National Health Institute to include the Diagnostics Development and Research Center and development of a One Health Laboratory will include a dedicated focus on climate change resilience and reducing GHG emissions to improve the country’s ability to adapt to the changing burden of disease from climate change: • Climate-shock-resilient building design will be used for the construction of the buildings (National Health Institute and One Health Laboratory). The project will finance technical assistance to develop climate-shock-resilient designs to ensure the building can Page 40 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) withstand the impacts of floods, storms, and landslides and is built in a location to minimize climate shocks. Climate resiliency measures, such as ensuring extra drainage, additional securing of windows and roofs, and measures to reduce the impacts of groundwater on buildings will go beyond standard practice. • The operations of the National Health Institute will include a dedicated focus on climate-sensitive diseases and understanding the links between climate change and zoonotic and other diseases in this context. This will include dedicated research subjects in these areas. (adaptation) • Aligned with Criteria 9.1 of the ‘Buildings, public installations and end-use energy efficiency’ section of the of the Multilateral Development Bank Mitigation Finance Methodology 25, the Project commits to adopting measures that substantially reduce net energy consumption, resource consumption, and CO2e emissions of the National Health Institute. Aligned with criteria 9.2 “Energy efficiency, renewable energy, CO2e emission reduction, and carbon sinks in green buildings” the project commits to securing post- construction EDGE level 1 certification for the Construction of the National Health Institute. As there are currently no energy efficiency standards in Rwanda, this goes beyond national standards for an estimated total of US$25.2 million. The project will finance technical assistance for energy efficiency assessments and implementing the EDGE building criteria, which will center around low embedded greenhouse gas emissions in the building materials used, thermal protection and low emissivity of the building envelope and glazing and passive energy design with active or passive façade shading elements as appropriate for the National Health Institute. The design and construction of the energy-efficient National Health Institute will contribute to reductions in greenhouse gas emissions. • Aligned with Criteria 9.1 of the ‘Buildings, public installations and end-use energy efficiency’ section of the of the Multilateral Development Bank Mitigation Finance Methodology, the project commits to adopting measures that substantially reduce net energy consumption, resource consumption, and CO2e emissions of the One Health Laboratory. Aligned with criteria 9.2 “Energy efficiency, renewable energy, CO2e emission reduction, and carbon sinks in green buildings” the project commits to securing post-construction EDGE level 1 certification for the construction of the One Health Laboratory. As there are currently no energy efficiency standards in 25 AfDB et al. 2023. Page 41 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Rwanda, this goes beyond national standards for an estimated total of US$15 million. The project will finance technical assistance for energy efficiency assessments and implementing the EDGE building criteria, which will center around low embedded greenhouse gas emissions in the building materials used, thermal protection and low emissivity of the building envelope and glazing and passive energy design with active or passive façade shading elements as appropriate for the One Health Laboratory. The design and construction of the energy efficient One Health Laboratory will contribute to reductions in greenhouse gas emissions. • Aligned with Criteria 9.5 of the Multilateral Development Bank Mitigation Finance Methodology, electrical laboratory equipment purchased through this subcomponent for the One Health Lab and National Health Institute will apply energy efficiency standards to ensure substantial reduction of energy consumption, resource consumption, or CO2e emissions compared to the current context in Rwanda, where such guidelines are absent. The cost of this electrical laboratory equipment will be an estimated US$5.01 million from IDA for the One Health Laboratory and US$9.65 million for the National Health Institute. This demonstrates the greenhouse gas substantiality of this project component in line with Box F.4 of the World Bank’s interim guidance on demonstrating substantial net greenhouse gas emissions reduction (internal draft), as this introduces, and thereby surpasses, national standards. By introducing energy efficiency requirements into equipment specifications, the project goes above and beyond current technology performance benchmarks. Energy Star efficiency standards, IEC energy efficiency standards, and similar viable standards for medical equipment will be used, exceeding mandatory minimum energy performance standards set in Rwanda, with particular reference to IEC 60601-1-9, ‘Medical Equipment – General requirements for basic safety and essential performance – Collateral Standard: Requirements for environmentally conscious design’. Rated criteria will be used in the procurement process to ensure the highest energy efficiency rating or labelling that allows the performance of quality laboratory and research services will be pursued (mitigation) Subcomponent 1.4: Information Strengthened digital disease surveillance platforms are essential to systems for HEs and the effectively collect data on climate-sensitive diseases and thereby address digitalization of the health sector the additional climate change attributable burden of these diseases; this will (US$0.15 million) help the country deal with the increased frequency and intensity of climate shocks by allowing for more effective use of health data during climate shocks. Page 42 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) Accordingly, the following activities are primarily climate change focused and driven: • Interactive data visualization tools and predictive models will focus primarily on tools and modelling for climate-sensitive diseases, the impacts of climate shocks on the health system and health service delivery and understanding the impact of climate change on other diseases (such as zoonotic diseases) in Rwanda. This will help the country deal with the additional burden of disease and changing transmission dynamics due to climate change. • Due to the role of climate change in driving HEs in Rwanda, disease surveillance digital platforms will be established to strengthen consistent data sharing on climate-sensitive disease outbreaks (human, animal, zoonotic, and environmental factors); data on climate shocks across multiple sectors and institutions to enhance rapid response. • District-based health risk registries and profiles will be established and updated annually, highlighting risks of climate-sensitive diseases and climate shocks. Specific content and modules on these diseases and shocks will be within the risk registries and profiles. • Establishing digitalized facility service availability and readiness of real-time monitoring will have a primary focus on monitoring climate shocks and climate sensitive disease outbreaks. This activity also intends to allow the country to use data effectively during climate shocks, when accessibility to climate-impacted areas is limited. The following activity is entirely focused on and driven by climate change. It intends to support the resilience of health systems to climate change: • This subcomponent will finance the integration of meteorologic data into the digital surveillance system (also financed by this subcomponent) to better understand the relationships between health and climate change and more effectively respond to the health impacts of climate change. The subcomponent will finance: i) technical assistance; ii) software and hardware to facilitate data systems integration. Climate change will be integrated into the following activities in the subcomponent: • Establishment of digital disease surveillance platforms are essential to effectively collect data on climate-sensitive diseases to address the additional burden of these diseases. This activity also intends to allow the country to use data effectively during climate shocks, Page 43 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) when accessibility to climate-impacted areas is limited. The activity forms the basis of the digitized surveillance system into which meteorologic data integration will be financed under this subcomponent. • Improvement of quality, reliability and geographic coverage of digital platforms covering key demographics will include measures on climate vulnerability of geographic areas to support the use of data to better understand the impact of climate change on health in Rwanda and adjust to the additional burden of disease and changing transmission dynamics. (adaptation) Component 2: Improving early detection of and response to HEs through a multisectoral approach (US$49.4 million) Subcomponent 2.1: Collaborative To respond to and manage the increasing disease burden and changing multisectoral gender-responsive transmission dynamics associated with climate change, this subcomponent surveillance and laboratory will finance the expansion of emergency response, testing, and diagnostic diagnostics (US$19 million) capacity with close attention to the expanding incidence and prevalence of climate-sensitive diseases, particularly water- and vector-borne diseases in the country. The following activity is primarily climate change driven and focused: • Re-establishment of the emergency operations center is being undertaken primarily to respond to climate shocks and outbreaks of climate-sensitive diseases, given their growing incidence and the changing transmission dynamics of climate-sensitive diseases. Guiding materials will include a dedicated focus on climate shocks and climate-sensitive disease outbreaks and response to these; the integrated data dashboards will monitor climate-sensitive diseases and climate shocks (landslides, extreme heat, floods, etc.) and will include meteorologic data. Climate change is integrated into the following activities: • This subcomponent will finance the expansion of multipathogen testing and sequencing abilities to improve characterization and monitoring of the impact of climate change on disease transmission and spread, pathogen biogeography, and new populations at risk. This will include a dedicated look at known climate-sensitive diseases (malaria and diarrheal diseases) and will explore changing transmission patterns of diseases with strong evidence for links with climate change (i.e., zoonotic diseases). • Strengthen environmental surveillance systems to monitor wastewater for emerging and re-emerging public health threats; this will include monitoring of climate-sensitive diseases (cholera, bacterial diarrhea, typhoid fever) with specific protocols and time Page 44 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) periods for monitoring these, including during climate shocks, such as flooding. • The subcomponent will support the development of predictive gender- sensitive models integrating data on climate change and climate-sensitive diseases to better understand disease transmission and spread and inform targeted measures. (adaptation) • Climate-shock-resilient building design will be used for the rehabilitation of the EOC. The project will finance technical assistance to develop climate-shock-resilient designs to ensure the building can withstand the impacts of floods, storms, and landslides and is built in a location to minimize climate shocks. Climate resiliency measures, such as ensuring extra drainage, additional securing of windows and roofs, and measures to reduce the impacts of ground water on buildings will go beyond standard practice. (adaptation) • Aligned with Criteria 9.1 of the ‘Buildings, public installations and end-use energy efficiency’ section of the of the Multilateral Development Bank Mitigation Finance Methodology, the project commits to adopting measures that substantially reduce net energy consumption, resource consumption, and CO2e emissions of the Emergency Operations Center. Aligned with criteria 9.2 “Energy efficiency, renewable energy, CO2e emission reduction, and carbon sinks in green buildings” the project commits to securing post- construction EDGE level 1 certification for the rehabilitation of the Emergency Operations Center. As there are currently no energy efficiency standards in Rwanda, this goes beyond national standards for an estimated total of US$17.5 million. The project will finance technical assistance for energy efficiency assessments and implementing the EDGE building criteria, which will center around low embedded greenhouse gas emissions in the building materials used, thermal protection and low emissivity of the building envelope and glazing and passive energy design with active or passive façade shading elements as appropriate for the Emergency Operations Center. The design and construction of the energy- efficient Emergency Operations Center will contribute to reductions in greenhouse gas emissions. (mitigation) Subcomponent 2.2: Emergency This subcomponent will support the strengthening of HE management, management, coordination, and coordination, and essential service continuity— in the context of climate essential service continuity (US$27 change being the primary impetus and key driver of over 70 percent of all million) HEs in Rwanda. The following activities will have a primary focus on climate change: Page 45 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) • Strengthening the quality of care by supporting the review of the quality-of-care provision; the ability to reorganize services during a HE will have a primary focus on the ability of health services to respond and reorganize during climate shocks and outbreaks of climate-sensitive diseases, given their primacy amongst HEs in the country. • Strengthening the referral system for HE cases will include specific materials on referrals of climate-sensitive diseases and a strong focus throughout on referrals during HEs. This will help the country deal with the increased incidence of climate-sensitive diseases and climate shocks and changing transmission dynamics of climate- sensitive diseases. • The implementation of updated threat and climate vulnerability mapping and risk identification will have a primary focus on risks and threats of climate-sensitive diseases and climate shocks; it will also assess risks to specific climate-vulnerable geographic locations and vulnerable groups including women and girls. • Developing capacity to quickly re-organize and utilize alternative service-delivery platforms to prevent service disruption during emergencies will have a primary focus on preventing service disruptions during climate shocks (primarily) as well as outbreaks of climate sensitive diseases. Specific operational plans for continuity of services during climate shocks will be covered and will comprise most of this activity. • Integrated community level nutrition services will help the country respond to the impacts of climate shocks on food security and undernutrition in Rwanda, which are directly linked. Services will be provided at the community level to more effectively identify children who are impacted by climate change and work with mothers and children on the nutritional impacts of climate change. This activity will cost US$1 million. • Assessing and expanding the capacity of the national emergency operating centers will have a primary focus on assessing the centers ability to respond to climate shocks and identifying gaps to improve capacity. This is a primary focus of this activity, which will inform reestablishment of the EOC in Subcomponent 2.1. • Climate-shock-resilient building design will be used for renovations of eight health centers. The project will finance technical assistance to develop climate-shock-resilient designs to ensure the building can withstand the impacts of floods, storms, and landslides and is built in an appropriate location to minimize climate shocks. Climate resiliency measures, such as ensuring extra drainage, additional securing of windows and roofs, and measures to reduce the impacts Page 46 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) of groundwater on the health centers will go beyond standard practice. (adaptation) • Aligned with Criteria 9.1 of the ‘Buildings, public installations and end-use energy efficiency’ section of the of the Multilateral Development Bank Mitigation Finance Methodology, the project commits to adopting measures that substantially reduce net energy consumption, resource consumption, and CO2e emissions of the eight health centers. Aligned with criteria 9.2 “Energy efficiency, renewable energy, CO2e emission reduction, and carbon sinks in green buildings” the project commits to securing post-construction EDGE level 1 certification for the rehabilitation of the eight health centers. As there are currently no energy efficiency standards in Rwanda, this goes beyond national standards for an estimated total of US$2.45 million. The project will finance technical assistance for energy efficiency assessments and implementing the EDGE building criteria, which will center around low embedded greenhouse gas emissions in the building materials used, thermal protection and low emissivity of the building envelope and glazing and passive energy design with active or passive façade shading elements as appropriate for the eight health centers. The design and construction of the energy-efficient eight health centers will contribute to reductions in greenhouse gas emissions. • Aligned with Criteria 9.5 of the Multilateral Development Bank Mitigation Finance Methodology, electrical medical equipment purchased through this subcomponent for health facilities will apply energy efficiency standards to ensure substantial reduction of energy consumption, resource consumption, or CO2e emissions compared to the current context in Rwanda, where such guidelines are absent. The cost of this electrical medical equipment will be an estimated US$0.50 million from IDA. This demonstrates the greenhouse gas substantiality of this project component in line with Box F.4 of the World Bank’s Interim guidance on demonstrating substantial net greenhouse gas emissions reduction (internal draft), as this introduces, and thereby surpasses, national standards. By introducing energy efficiency requirements into equipment specifications, the project goes above and beyond current technology performance benchmarks. Energy Star efficiency standards, IEC energy efficiency standards, and similar viable standards for medical equipment will be used exceeding mandatory minimum energy performance standards set in Rwanda, with particular reference to IEC 60601-1-9, ‘Medical Equipment – General requirements for basic safety and essential performance – Collateral Standard: Requirements for environmentally conscious design’. The highest energy efficiency rating or labelling that allows the performance of quality medical and laboratory services Page 47 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) adequately will be pursued. In the procurement process, rated criteria will be used. The highest energy efficiency rating or labelling that allows the performance of quality laboratory services adequately will be pursued. (mitigation) The following activities are entirely focused on and driven by climate change: • Health facility level climate emergency preparedness and response plans will be developed for each facility to support adaptation to the increased incidence of climate shocks. (adaptation) Subcomponent 2.3: Risk The subcomponent will finance activities on the development of risk Communication and Community communication, community engagement, empowerment and social Engagement, empowerment, and protection for HEs. Given that over 70 percent of all HEs in Rwanda are Social Protection for all HEs driven by climate change—including climate-sensitive diseases, climate- (US$0.40 million) related health risks (direct injuries and mortalities, heat-related illnesses) and climate shocks—the community engagement and communications activities in this subcomponent are primarily focused on community engagement on the health impacts of climate shocks and climate-sensitive diseases. These primarily climate change focused activities are: • Community health workers to create community awareness on climate change, climate shocks and related health risks including impacts on worsening water- and vector-diseases in the country; health promotion behavior such as hand washing and proper hygiene to reduce the spread of diarrheal diseases, and climate shocks protection awareness. • Development of appropriate public health risk communication will focus primarily on climate change and its impacts. Plans for these communication exercises will be structured to reflect this primary focus. All climate awareness programs will target vulnerable populations, and vulnerable communities in remote and rural areas of the country. (adaptation) The following activities are entirely focused on climate change: • A national climate and health adaptation plan will be developed to guide the design and prioritization of strategies to address climate change health risks, including a guide for involvement of relevant stakeholders and a plan of action. Page 48 The World Bank Rwanda Health Emergency Preparedness, Response and Resilience Project Using the Multiphase Programmatic Approach (P504764) • Support of the assessment of health system performance during climate shocks to identify gaps in service continuity during climate shocks and climate HEs—and to design measures to bridge these gaps. • Execution of climate shock response simulation exercises focusing on the impacts of climate change (floods, landslides, droughts) and on the increasing the burden of climate sensitive diseases now and in the future to inform adaptation measures. (adaptation) Component 3: Project Management (US$5.0 million) Subcomponent 3.1 Strengthening This subcomponent will monitor the project’s climate activities and so project monitoring and evaluation should be assessed at the same rate as the project’s other activities. (M&E) (US$0.50 million) Subcomponent 3.2: Providing need- This subcomponent will provide technical assistance for and generate based technical assistance and learning on the project’s climate activities and so should be assessed at the facilitating learning agenda same rate as the project’s other activities. (US$1.50 million) Subcomponent 3.3: Strengthening This subcomponent will provide strengthen management for the project’s project management through climate activities and so should be assessed at the same rate as the support of the implementing project’s other activities. institutions and multisectoral collaboration (RBC, RAB, RDB, REMA, GMO) (US$3.00 million) Page 49