AIDE-MÉMOIRE RWANDA COVID-19 EMERGENCY RESPONSE PROJECT (IDA-E0220, IDA-7092; GFF-TF0B6226) WORLD BANK IMPLEMENTATION SUPPORT MISSION September 16-20, 2024 I. INTRODUCTION 1. From September 16-20, 2024, the World Bank Health, Nutrition and Population team carried out an Implementation Support Mission for the Rwanda COVID-19 Emergency Response Project. The objectives of the mission were to: (i) review the Project implementation progress with emphasis on: (a) the Contingent Emergency Response Component 4 (CERC) and (b) Protecting Essential Health and Nutrition Services (Component 5); (ii) identify key implementation bottlenecks, agree on actions to address them, and accelerate implementation; and (iii) assess compliance with fiduciary, environmental and social safeguards. The mission included joint field visits to selected locations in Nyabihu, Rubavu, and Rutsiro Districts to review the progress of activities on the ground. 2. The World Bank (WB) team (Annex 1) would like to express its appreciation for the excellent collaboration and cooperation from officials of the Ministry of Health (MoH), the Ministry in Charge of Emergency Management (MINEMA), and Rwanda Biomedical Centre (RBC). The WB team is particularly grateful for the high-quality discussions and guidance from Mr. Zachee Iyakaremye, Permanent Secretary (MoH), Mr. Philippe Habinshuti, Permanent Secretary (MINEMA), Prof. Claude Mambo Muvunyi, Director General of RBC; Mr. Jean Simpenzwe Pascal, Vice Mayor in charge of Social Affairs (Nyabihu District), Mr. Prosper Mulindwa, Mayor of Rubavu District, and Ms. Dative Kayitesi, Mayor of Rutsiro District, and Mr. Emmanuel Uwizeyimana, Vice Mayor in charge of Economic Development (Rutsiro District). A full list of officials met during the mission is provided in Annex 2. The wrap-up meeting, co-chaired by Mr. Zachee Iyakaremye (PS MoH), and Mr. Philippe Habinshuti (PS MINEMA), was held on September 26, 2024. The Aide Memoire (AM) was subsequently shared with counterpart teams for comments. II. IMPLEMENTATION PROGRESS AND KEY FINDINGS Table 1: Key Project Data As of September 26, 2024 Summary (US$) Source of funds Committed Disbursed (US$, Undisbursed % Disbursed (US$, Million) Million) (US$, Million) IDA 76.25 68.47 6.94 91% Trust Fund 15.94 12.41 3.52 78% Total 92.19 80.89 10.46 89% Table 2: Summary Status of Financing (US$) Financing WB Approval Effective date Closing date Project Cost Amount Amount (US$ Million) Disbursed Undisbursed (US$ Million) (US$ Million) Parent IDA-66150 Apr 07, 2020 Apr 20, 2020 June 30, 2022 14.25 14.25 0.00 IDA Credit (100%) First Additional Financing TF-B4324 Pandemic Emergency Nov 30, 2020 Dec 06, 2020 Feb 28, 2021 0.94 0.94 0.00 Financing Facility (PEF) Grant (100%) Second Additional Financing IDA-68710 Apr 16, 2021 June 21, 2021 June 30,2025 15.00 14.84 0.005 IDA Credit (99%) (0.3%) IDA-D8050 Apr 16, 2021 June 21, 2021 June 30, 2025 15.00 14.92 0.033 IDA Grant (99.8%) (0.2%) 1 - Official Use Only Financing WB Approval Effective date Closing date Project Cost Amount Amount (US$ Million) Disbursed Undisbursed (US$ Million) (US$ Million) TF-0B6226 Apr 16, 2021 Sept 2, 2021 June 30, 2025 15.00 11.48 3.52 Global Financing Facility (GFF) Grant (77%) (23%) Third Additional Financing IDA-70920 Mar 31, 2022 June 6, 2022 June 30, 2025 16.00 11.15 4.15 IDA Credit (70%) (30%) IDA-E0220 Mar 31, 2022 June 6, 2022 June 30, 2025 16.00 12.89 2.34 IDA Grant (80.6%) (14.6%) Total 92.19 80.89 (89%) 10.46 (11%) Progress Towards Achieving Project Development Objective (PDO) 3. The Project was initially designed with the overall objective of contributing to the prevention, detection and responding to the threat posed by COVID-19 and strengthening the national system for public health preparedness in the Republic of Rwanda. In January 2024, the “Crisis and Emergency” component was included. Consequently, the Project Development Objective (PDO) was amended as follows: (i) to prevent, detect, and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in the Republic of Rwanda; and (ii) provide immediate and effective response to an eligible crisis or emergency. The Project has been under implementation for 54 months (4.5 years) with steady progress towards achieving the PDO. With support from different sources of financing (internal revenues, WB, and other development partners), Rwanda has performed over 6.1 million COVID-19 tests and reported over 133,208 cases1 with a cumulative positivity rate of 2.2 percent and an attack rate of over 1,000 per 100,000 population. Sadly, 1,468 lives have succumbed to the pandemic (representing a case-fatality rate of 1.1 percent and a death rate of 112 per 1 million population)2. 4. With respect to vaccination, as of February 5, 2024, over 83 percent of the Rwandan population have received at least one dose of COVID-19 vaccine while 79.9 percent of the population (equivalent to 10.8 million people) are now fully vaccinated, and 79.7 percent of the population aged 18 years and above (6.04 million people) have received a booster dose. The government had set a target to reach a full vaccination coverage rate of 86 percent of the population by the end of December 2022 (including children aged 5 to 11 who represent about 17 percent of the population)3. 5. Following the flood and landslide disasters that hit different parts of the country in Northern and Western Provinces in May 2023, the Government submitted on August 3, 2023, a request to reallocate the remaining IDA balance to Emergency Expenditures. Overall Implementation Progress 6. As of September 20, 2024, US$80.89 million (89 percent percent) of the US$92.19 million have been disbursed to support the implementation of activities on the ground and the procurement of supplies, equipment and services. The Project enjoys high-level political support and is well managed by RBC through its Single Project Implementation Unit (SPIU). It has also progressed well in the achievement of the indicators as explained in the section on Results Framework. 7. Activities under Component 1: Case Detection, Confirmation and Contact Tracing (US$6.84 million) have been successfully implemented as reported in the previous missions and Aide Memoires. 1 WHO (Rwanda). Data reported to WHO in the last 24 hours. Latest update: 19 December 2023 at 07:43 pm GMT+2. COVID-19 (rbc.gov.rw) 3 Covid-19 Cases in Rwanda Public - New Version 2 (rbc.gov.rw) 2 - Official Use Only Two activities are pending under Component 2: Public Health Measures and Clinical Care Capacity (US$69.25 million) – Health System Strengthening sub-component (as indicated in paragraph 12 below). 8. Since all COVID-19 related activities have been fully achieved since June 2023, the current mission focused on the status of pending health system-related activities and the new crisis and emergency response activities under the CERC implemented in collaboration with MINEMA and affected districts. 9. At the end of the January 2024 mission, a total of US$16.53 million was available for disbursement. Since then, US$6.52 million (39 percent) was disbursed. At the end of the current mission US$10.01 M (including IDA US$6.49 M and GFF Grant US$3.52 M) was available for disbursement and commitment for the next nine (9) months until the Project closure. The government team was encouraged to develop and implement a catch-up plan to ensure the completion of activities by the Project timeframe (with a non-extendable closure date of June 30, 2025). Implementation Progress per Component and Sub-Component COMPONENT 1: CASE DETECTION, CONFIRMATION AND CONTACT TRACING (US$6.84 million). 10. This component has been fully executed and results satisfactorily achieved. All details of the accomplishments were described in the AM of June 2022. COMPONENT 2: PUBLIC HEALTH MEASURES AND CLINICAL CARE CAPACITY (US$69.25million). 11. Two major activities under the Health Systems Strengthening Sub-component are still pending: (i) the procurement of six trucks to support the distribution of oxygen (US$0.31 M), and (ii) the installation of a solar energy system at Nyamata mobile hospital (US$1.02 M). Given the importance of these activities in pandemic preparedness and response, with consideration of the current double outbreak of Mpox and Marburg Virus Disease (MVD) in Rwanda, RBC should ensure that both activities are completed as soon as possible. Table 3: Tenders to be accelerated Activity description Status Strengthen the national oxygen distribution Pending. The first and second tender processes failed. systems to allow safe and efficient supply of According to RBC, the first tender failed because the supplier oxygen directly to the patients - Equip CHUK, proposed to change the technical specifications of the trucks, CHUB, Kibuye, RMH, Kibungo and Ruhengeri which RBC did not agree with. The second tender failed due hospitals with oxygen delivery trucks to a lack of qualified suppliers. RBC is initiating the third tender process Acquisition and installation of a solar energy RBC has completed the feasibility study. RBC will initiate the system to support continuous energy supply to tender process the Nyamata Emerging Infectious Disease Isolation and Treatment Center COMPONENT 3: PROGRAM/PROJECT MANAGEMENT AND MONITORING & EVALUATION (M&E) (US$1.1 million) 12. Project Management. The Project continues to be well-managed by the RBC/SPIU with 5 staff dedicated to the implementation of project activities. The mission noted however that two key members of the RBC/SPIU have resigned, and the two positions are vacant: the Social Safeguards Specialist and the Environment Safeguards Specialist. The mission recommended that both positions be filled by December 31, 2024, to effectively implement activities related to crisis and emergency response in full compliance with the provisions of the Financing Agreement. 3 - Official Use Only 13. Monitoring and Evaluation. For data collection and progress reporting, the Project relies on the national Health Management Information System (HMIS), which is an integrated web-based platform built on the District Health Information System 2 (DHIS2) to collect routine data for the health sector. The HMIS/DHIS2 is comprised of different modules that collect aggregate data on outpatient consultations, maternal and child health (MCH), infectious diseases, non-communicable diseases, hospitalization, vaccination, management of tracer drugs, and laboratory. The system also includes an Integrated Disease Surveillance and Response (IDSR) module that uses the Indicator-Based Surveillance (IBS) approach to enable the prompt detection of priority (national notifiable) diseases (including COVID- 19). Since the integration of COVID-19 into the IDSR/IBS, new cases of COVID-19 are reported weekly every Monday before midday and published in the WEEKLY EPIDEMIOLOGICAL BULLETIN. COMPONENT 4: CONTINGENCY EMERGENCY RESPONSE COMPONENT (CERC) 14. On January 18, 2024, the World Bank approved the Government request of August 3, 2023, to reallocate the remaining IDA balance to Emergency Expenditures to respond to the flood and landslide disasters that occurred in May 2023 in the Northern and Western provinces of Rwanda. To provide quick relief, US$9 million was availed to support (i) the rehabilitation of 1,322 partially damaged houses (equivalent to 41 percent of damaged houses); (ii) the construction of 463 houses destroyed (17 percent of destroyed houses); and (iii) the establishment of 14 emergency evacuation sites (EESs) in 14 districts. 15. Current progress: (i) the rehabilitation of the partially damaged houses is progressing well, with a progress rate of 60 percent; (ii) the construction of the destroyed houses has not yet started; (iii) the establishment of the 14 emergency evacuation sites is pending. Six of the sites will be established on land that is already owned by the Government; the other eight sites are located on privately owned property. One of the factors that is delaying the implementation of the activities is that the Government has to provide the land (through expropriation) for the construction of the 463 houses destroyed and for 8 emergency evacuation sites. The Project will close on June 30, 2025, and there will be no possibility to extend the Project beyond the closing date. In case these activities are not completed by the project closing date, they will have to be financed by the Government of Rwanda. The WB and Government teams have agreed to prepare a follow-up table to ensure the proper monitoring of the activities (see Annex 6). 16. Additional Districts in CERC: As part of the ongoing implementation of the CERC activities, MINEMA, in collaboration with district officials, has reassessed the beneficiaries and observed some changes within the target population from the initial assessment. Specifically, some families who were initially identified as disaster-affected have either found solutions through their means or received support from other sources. These factors have resulted in a reduction in the number of beneficiaries in the initial plan while resources are already allocated. Therefore, MINEMA expressed the request to include nine additional affected districts in CERC. The proposed additional districts are Rusizi, Nyamasheke, Nyamagabe, Muhanga, Gakenke, Gicumbi, Musanze, Gasabo and Rulindo. MINEMA, in collaboration with the additional districts, has conducted a quick needs assessment in the proposed districts, collecting data on the number of families affected by the disaster in May 2023. The identified affected population in each district is as follows: Muhanga (161), Nyamasheke (74), Rusizi (11), Nyamagabe (87), Gakenke (243), Gicumbi (100), Musanze (203), Gasabo (54). MINEMA will conduct a detailed analysis to ensure that only the most vulnerable families are prioritized. This approach will also allow MINEMA to remain within the initial target of supporting 1,322 houses, for which resources have already been allocated and the Project will be implemented within the set timeframe as agreed upon at the wrap-up meeting. 4 - Official Use Only COMPONENT 5: PROTECTING ESSENTIAL HEALTH AND NUTRITION SERVICES (US$15.00 million from the GFF grant) 17. As of the date of the mission, US$11.48 million (77% of the total grant) was disbursed for the execution of the work and procurement plan. Most of the activities under this component were executed with satisfactory results, except the following: • Provision of Nutrition and MNCH Oxygen Commodities: A tender for oxygen compressor has been launched and is currently under evaluation. The patient monitors for the 20 renovated sites have not yet been delivered. • Capacity building for health providers and CHWs: After achieving the targets, $254,679 is still available. RBC was asked to propose additional activities that align with the GFF mission and the provisions of the Grant Agreement. • Strengthening the health resources tracking system and promote interoperability for improved data visualization and analytics. Only $150 out of $3,252,500 has been disbursed. During the mission, the Research, Innovation and Data Science (RIDS) Division of RBC presented a budget reallocation proposal that was approved by the WB task team. The remaining funds will be used to support (i) early detection of risky pregnancies, (ii) referral system for pregnant women at risk, (iii) quality of care at hospitals, (iv) food uptake, hygiene, and social determinants, and (v) postpartum follow-up. A detailed work plan was presented. However, the feasibility of implementing this work plan within the remaining timeframe seems challenging. It has been suggested that the procurement teams of RBC and the WB meet to evaluate the feasibility of procurement within the given timeframe. A period of four months has been allocated to accelerate activities and disbursement. If progress is not satisfactory, another reallocation will be necessary • Integration of NCD Screening into MNCH program. After achieving the targets, $285.000 is still available. RBC was asked to propose additional activities that align with the GFF mission and the provisions of the grant agreement. III. FIDUCIARY MANAGEMENT 18. Procurement. There is significant progress made in implementation of the planned procurement activities since the beginning of the COVID-19 Project. Procurement activities allocated to the Project in the initial period were completed. The Project Procurement Strategy for Development (PPSD) has been prepared including the procurement plan for an estimated three (3) new procurement activities under CERC (construction and rehabilitation of houses and establishing emergency evacuation sites). MINEMA has prepared the list of these activities as per the PPSD. The CERC procurement activities have started, and MINEMA finalized the work plan including the procurement plan estimated at US$9 million. The rehabilitation of the 1,322 partially damaged houses is at 60 percent; (ii) the construction of the 463 houses destroyed has not yet started; and (iii) the establishment of the 14 emergency evacuation sites is pending. Major delays come from the fact that the Government has not yet provided the sites for the construction of the destroyed houses and the establishment of the evacuation sites. The mission agreed on preparing a follow-up table to ensure proper monitoring of activities. Further, while these activities are reflected in the revised PPSD, they are not reflected in Systematic Tracking of Exchanges in Procurement (STEP). With respect to that, the mission recommended that the STEP be updated with immediate effect. 19. Given the level of progress made in completing the procurement activities, the Project procurement performance rate of Moderately Satisfactory is recommended. 20. Financial Management (FM). The overall financial management rating for the Project is Moderately Satisfactory, and the financial management residual risk rating is classified as Substantial. 5 - Official Use Only Good achievements have been noted in terms of timely submission of Interim Financial Reports (IFRs) of good quality and clean audit opinion on the financial statements and compliance with applicable laws, regulations and guidelines for the year ended June 30, 2023. Areas that require attention include: (i) weak planning and budget monitoring systems; (ii) large undisbursed/uncommitted funds with 8 months left to Project closure amounting to US$ 3,520,580 under Grant TF OB6226; EUR 3,822,153 (US$ 4,119,326) under IDA Credit 70920 and XDR 1,763,942 (USD 2,2342,373) under IDA Grant E0220; (iii) IDA 66150 has an undisbursed balance of EUR 346,081 that cannot be utilized on eligible pending activities because the IDA 66150 is closed; (iv) the audit report for the year ended June 30, 2023 issued a qualified (unclean) audit opinion on the realization of value for money; (iv) the audit reports noted missing and stolen assets; and (v) delayed implementation of audit report recommendations. An action plan has been prepared to address these gaps. IV. ENVIRONMENTAL AND SOCIAL (E&S) RISK MANAGEMENT 21. Environmental Risk Management. The environmental risk management performance is rated as Moderately Satisfactory. This mission was mainly focused on CERC activities which include reconstruction of residential houses, rehabilitation of partially affected homes, and construction of emergency shelters for communities affected by floods. The mission noted that details of the CERC implementation approach remained unclear. It is important that the approach being taken in the implementation of CERC be well documented and the Emergency Operational Manual (EOM) be updated. It was agreed that MINEMA would provide a description of the CERC implementation approach detailing the phases and their respective timelines. The CERC ES implementation faced a challenge as there are no environment safeguards and social safeguards specialists in RBC/SPIU working on ES requirements. 22. E&S risk management instruments. The Environment and Social Management Plan (ESMP) and Resettlement Action Plan (RAP) were shared with WB staff for initial comment on September 23, 2024. An initial review by WB E&S risk management team noted that despite having provided an ESMP template on the ESMF addendum for the rehabilitation of damaged household dwellings, the ESMP submitted was prepared under the outdated WB Environmental and Social Operational Policies. It is recommended that a compliant ESMP be prepared for the rehabilitation works by November 30, 2024. 23. Social Risk Management. The social risk performance is rated Moderate Satisfactory. Under the CERC activities, RBC has prepared a Stakeholder Engagement Plan (SEP) and the Environmental and Social Management Framework (ESMF)-Addendum following the WB approval and disclosure to the public. 24. Land Acquisition. The mission was informed that MINEMA is in the process of acquiring land for the construction of 463 houses and the establishment of 8 evacuation sites. This will involve obtaining consent from community members who are willing to sell part of their land for the construction of houses for the affected households and for the establishment of emergency evacuation shelters as opposed to the initial Project preparation agreed upon on the approach to land acquisition. The WB team advised the client to prepare a detailed report on the planned construction activities to be submitted for review, after which the WB will provide specific guidance on the land acquisition process to be followed. Additionally, the WB recommended that MINEMA and RBC engage the Ministry of Finance and Economic Planning (MINECOFIN) on the allocation of counterpart funding to avoid disruption in Project implementation due to delays in the availability of expropriation funds. Given the new approach, which will include land acquisition, RBC was advised to prepare the Project RAP, update the Stakeholder Engagement Plan (SEP) and a Labor Management Plan (LMP) to reflect on: (i) issues related to land acquisition processes and activities, (ii) stakeholder engagement and consultations conducted, grievance 6 - Official Use Only redress mechanisms (GRM), and (iii) labor management issues. The prepared instruments will be submitted for WB review and clearance prior to construction works. 25. Stakeholder Engagement. The mission emphasized the importance of both SPIUs conducting consultations with community members willing to sell their land, as well as with other stakeholders involved in the land acquisition process, to ensure that the process is properly managed and documented. A comprehensive consultation report, along with signed consent forms from each individual indicating their willingness to sell their land, will be included as part of the report. 26. Grievance Redress Mechanism (GRM). The Project E&S teams (RBC & MINEMA) will facilitate the establishment of Grievance Redress Committees (GRCs) and provide them with training on handling complaints as soon as affected people have been identified. The WB’s E&S team advised RBC/SPIU to ensure the timely establishment of GRCs and to provide relevant training and guidance needed for handling complaints for new GRC members and to share with the WB a brief note on the GRM establishment indicating its structure, the roles and responsibilities of each committee member, and a report on all training conducted. 27. Staffing. RBC currently lacks a dedicated Environmentalist and Social Specialists to oversee safeguards compliance. The mission was informed that the recruitment process for these positions is ongoing. In MINEMA, both Environment and Social Specialists are already in place. The mission encouraged the RBC/SPIU to accelerate the hiring process so that RBC staff can collaborate closely with the MINEMA team to monitor safeguards compliance for the proposed CERC activities. V. RESULTS FRAMEWORK 28. The mission reviewed the status of the Project results framework (RF), which is comprised of 20 indicators, including six PDO-level indicators related to COVID-19 investigation, case management and vaccination, and 14 intermediate results indicators (IRIs), including seven indicators related to COVID-19 response, and another seven for health system strengthening (HSS) and essential health services (EHS). Given the current status of the COVID-19 pandemic in Rwanda, all PDO-level indicators and IRIs related to COVID-19 have been considered achieved. The review focused on the remaining seven IRIs related to HSS and EHS4. The mission appreciated the overall performance level for those indicators and considered them to be on track to be achieved at the end of the Project implementation period (June 30, 2025). VI. NEXT STEPS AND AGREED ACTIONS 29. Given the upcoming closure of the Project, the mission agreed on close monitoring of the implementation to ensure a successful and timely closure. It means: (i) monthly meetings will be held on Component 5, and (ii) CERC component will have biweekly sessions to assess the progress of works. 4List of reviewed indicators during the mission. Annex 2 provides the performance level of each indicator, HSS: (i) Number of people screened for underlying chronic conditions, disaggregated by sex and age group (Number), (ii) Percentage of targeted hospitals with functioning oxygen therapy system (Percentage); EHS: (iii) Number of outpatient consultations, disaggregated by age and sex (Number), (iv) Number of new acceptors of modern contraception (Number), (v) Number of deliveries conducted within the facility (Number), (vi) Number of pregnant women receiving four antenatal care visits (Number), (vii) Number of infants receiving Pentavalent 3 vaccine (Number). 7 - Official Use Only Table 4: Agreed on Actions Area Action Timeline Responsible party 1. Project RBC to speed up the implementation of the following December 31, RBC implementation / pending activities under Component 2, sub- 2024 Procurement component 5 – Health System Strengthening: (i) Equip CHUK, CHUB, Kibuye, RMH, Kibungo and Ruhengeri with oxygen delivery trucks, and (ii) Acquisition and installation of a solar energy system to support continuous energy supply to the Nyamata Emerging Infectious Disease Isolation and Treatment Center. 2. Project Fast track recruitment for the replacement of the December 31, RBC management / E&S Environmental Specialist and Social Specialist for RBC- 2024 risk management SPIU 3. CERC / E&S risk To provide a description of the CERC implementation November 29, RBC in management approach to the WB E&S risk management team, 2024 consultation with detailing the phases and their respective MINEMA timelines/implementation roadmap. 4. CERC / E&S risk To prepare an ESMP for the rehabilitation of damaged November 30, RBC in management houses to comply with the ESSs of the WB ESF 2024 consultation with MINEMA 5. CERC To exclude from the CERC activities related to land December 31, RBC in implementation acquisition for the construction of new houses as well 2024 consultation with as for the establishment of emergency evacuation MINEMA sites (EES) on the 8 sites identified on private land. The focus should be put on completing the rehabilitation of partially damaged houses and the establishment of EES that will be established on state/public land. 6. MINEMA and RBC to prepare and submit to the Bank December 31, RBC in a detailed report indicating the number of houses 2024 consultation with rehabilitated/ constructed vs. the number of houses MINEMA planned per land ownership type (beneficiary land, public land, purchased land) 7. CERC/ Procurement Submission of procurement progressive plan to be November 29, RBC updated, current activities and status report 2024 8. Essential health RBC to submit a detailed proposal /activities for the November 29, RBC/MCCH services / Sub- utilization of the remaining balance of $254,679. The 2024 component 5.5. proposal should be aligned with the GFF mission and Capacity building of the provisions of the Grant Agreement. health providers and CHWs 9. Essential health RBC and WB Procurement Specialists to meet to (i) November 31, RBC and World services / 5.7. evaluate the feasibility of procurement within the 2024, for the RBC- Bank strengthening the given timeframe. A period of four months has been WB meeting, health resources allocated to accelerate activities and disbursement. If (ii) January 31, tracking system and progress is not satisfactory, another reallocation of 2025, for the promote the remaining balance ($3,252,500) will be necessary. second interoperability for reallocation improved data decision visualization and analytics 10. E&S risk RBC to investigate why medical waste bags color- December 31, RBC management coded for infectious waste (Red bags) are used in all 2024 waste and take appropriate steps (such as to ensure adequate supply of appropriate medical waste bags are available, and / or provide appropriate training of health centre level waste managers and workers) 8 - Official Use Only Area Action Timeline Responsible party 11. Project • To ensure realistic forecasts, the entity should November 29, RBC implementation / engage all stakeholders effectively during the 2024 Financial planning and budgeting process consider revision Management of the FY 2024/2025 budget to make it more realistic. • Prepare quarterly budgets and monitor budget execution quarterly. The analysis should include actual quarter budget Vs the actual expenditure for the quarter; the budget to the reporting date Vs the actual expenditure to the reporting date; committed amount and list of major expenditure to the closing date indicating the timelines for payment for close monitoring 12. Financial Submit justification for the potential ineligible November 29, RBC Management expenditure, together with the IFR for the quarter 2024 ending September 30, 2024 13. Financial For the large undisbursed balances, submit a cashflow November 29, RBC Management forecast with a list of major expenditure that will be 2024 incurred before Project closure. Align the forecast with the procurement plan 14. Financial The implementing entities should publish their Upon submission RBC Management audited financial statements for transparency of the Audit reports to the Bank 15. Financial Submit an Action plan for implementation of Audit November 29, RBC Management recommendations, together with the IFR for the 2024 quarter ending September 30, 2024 16. Financial Second additional Financing: Submit a withdrawal Immediate RBC Management application to request for the Exchange gains under IDA 68710 Credit amounting to XDR 36,940.23 (USD 49,170.03) and IDA D8050 Grant amounting to XDR 25,299.13 (USD 33,674.91) for utilization Table 5: Status of Agreed on Actions in January 2024 No Areas Actions Responsible Due date Current status 1. Essential health Send the updated plan for the Moh/RBC March 31, 2024 Implemented services implementation of priority activities under 5.5 Capacity Building: Strategic Information and Decision- Making 2. Implementation Send the status of the procurement MoH/RBC / March 31, 2024 Implemented Oxygen / Procurement and oxygen delivery across districts MTD 3. CERC Share the updated plan de RBC and March 31, 2024 Implemented renovations and constructions and MINEMA procurement under the CERC considering available balance (US$9million) 4. E&S risk Management Share evidence of transfer of RBC/SPIU June 30, 2024 Pending ownership for acquisitions of land for the establishment of Emergency Evacuation Shelters and for relocation sites. 5. E&S risk Management Prepare and share with WB, RBC/SPIU June 30, 2024 Implemented Resettlement Action Plans per relocation activity. 9 - Official Use Only No Areas Actions Responsible Due date Current status 6. E&S risk Management Establish GRCs for relocation RBC/SPIU June 30, 2024 Pending affected parties. Share a GRM for CERC activities with WB 7. E&S risk Management Share draft ESMPs for Emergency RBC/SPIU June 30, 2024 Implemented Evacuation Shelters with WB 8. E&S risk Management Share draft ESMPs for relocation RBC/SPIU June 30, 2024 Implemented works with WB 9. Project Management, To review the status and MOH-RBC October 31, Ongoing M&E and Learning functionality of the procured goods 2024 in the Project, including the assessment of the functionality of the works performed for isolation and ICU units and the oxygen piping in the country 10. Procurement Upload all procurement documents RBC/SPIU March 31, 2024 Ongoing for clearance before implementing the PP 11. Financial Management Preparation and monitoring of RBC/SPIU March 31, 2024 Implemented quarterly budget 12. Financial Management Presentation and retention of RBC/SPIU After Ongoing evidence of the internal audit report completion of to the audit committee every audit 13. Financial Management Take timely action on audit report RBC/SPIU March 31, 2024 Ongoing findings, particularly on potential ineligible expenditure as well as missing and stolen asset 14. Financial Management Publish audited financial statements RBC/SPIU June 30, 2024 Pending for transparency 10 - Official Use Only Annex 1. World Bank Team 1. Patrice Mwitende (Senior Health Specialist, and Task Team Leader), 2. Amparo Gordillo-Tobar (Senior Health Economist and Co-Task Team Leader), 3. Lisa Diarra (Senior Operations Officer and GFF Country Focal Point), 4. Yacob Wondimkun Endaylalu (Senior Environmental Engineer), 5. Jacqueline Bugunya (Senior Financial Management Specialist), 6. Sreenivas Devarakonda (Senior Procurement Specialist), 7. Chantal K. Umulinga (Social Development Specialist), 8. Willy Niyonteze (Procurement Specialist), 9. Sujani Eli (Senior Operations Assistant), Nancy Umwiza (Team Assistant), 10. Denis Rugege (Consultant, Environment & Social Safeguards), 11. Janet Umugwaneza (Consultant, Environnent Safeguards), 12. Indra Iliza Nyamvumba (Consultant, Public Policy and Results Measurement), 13. Nathalie Umutoni (Consultant, Public Health 11 - Official Use Only Annex 2. List of key counterparts met during the mission No. Name Position Agency Email 1. Mr. Zachee Iyakaremye Permanent Secretary MoH zachez.iyakaremye@moh.gov.rw 2. Mr. Habinshuti Philippe Permanent Secretary MINEMA ps@minema.gov.rw 3. Prof. Claude Mambo Muvunyi Director General RBC claude.muvunyi@rbc.gov.rw 4. Mr. Theo Principe Uwayo Chief Finance Officer RBC principe.uwayo@rbc.gov.rw 5. Ms. Anais Umukoza Advisor of Director General Office RBC Anais.umuhoza@rbc.gov.rw 6. Dr. Francois Uwinkindi Division Manager, NCD Division RBC Francois.uwinkindi@rbc.gov.rw 7. Dr. Gilbert Biraro SPIU Coordinator RBC gilbert.biraro@rbc.gov.rw 8. Mr. Ntaganda Evariste CVD Director RBC Evanste.ntaganda@rbc.gov.rw 9. Dr. Eric Remera DMIRIDD RBC Eric.Remera@rbc.gov.rw 10. Mr. Jminania Jacque Procurement Specialist MINEMA jminania@minema.gov.rw 11. Mr. Samuel Nzitonda Procurement Coordination Specialist SPIU/RBC Samumel.nzitonda@rbc.gov.rw 12. Mr. Jean Piere Musabyimana Bioinformatics Analyst RBC jpierre.musabyimana@rbc.gov.rw 13. Mr. Frank Dushimana Conservation Specialist RDB frank.dushimana@rdb.rw 14. Dr. Edson Rwagasore Division Manager, PHS-EPR RBC Edison.rwagasore@rbc.gov.rw 15. Mr. Simon Pierre Niyonsenga Director of Diabetes RBC niyonsengasp@gmail.com 16. Mr. Isaac Mbwirabumva Program Manager SPIU/RBC isaac.mbwirabumva@rbc.gov.rw 17. Mr. Jean de Dieu Hakizimana AEFIs Surveillance and Monitoring Officer RBC jdieu.hakizimana@rbc.gov.rw 18. Mr. Francois Xavier Kaneza Financial Specialist RBC Kaneza.fxaver@rbc.gov.rw 19. Mrs. Nirere Etienne Director of Health Rutsiro District nirereetienne@gmail.com Mr. Ntawuruhunga Abdul 20. ECD Focal Point Rutsiro District ntawuruhungaabdul@gmail.com Madjidi 21. Mr. Ntwali Ndizeye Head Medical Advisory Services RSSB Ntwali.ndizeye@rssb.rw 22. Mr. Arch. Joe Maniraguha Architect/MF Infra Specialist RBC Joediogene.maniraguha@rbc.gov.rw 23. Dr. Gad Nshimiyimana Officer/NCDs RBC Gad.nishimiyimana@rbc.gov.rw 24. Dr. Huges Valois Mucunguzi Director of AF & HPD unit RBC Huges.valois@rbc.gov. rw 25. Ms. Aline Umimana DM MCCH RBC Aline.uwimana@rbc.gov.rw 26. Mr. Gonzagne Karagire Assistant SPIU Coord MINEMA gkaragire@minema.gov.rw 27. Mr. Placide Nkusi Environmental Specialist MINEMA pnkusi@minema.gov. rw 28. Mr. Dorothee Teganeza Financial Manager MINEMA dteganeza@minema.gov.rw 29. Mr. Virgile Mugisha CERC Project Manager MINEMA vmugisha@minema.gov.rw Annex 3: Updated Results Framework (September 2024) PDO Level indicators No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value Prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems 1 Proportion of suspected cases of 07-Apr-2020 80.00 20-Sept-2024 100.00 30-Jun-2025 100.00 Achieved since June 2023 COVID-19 reported and investigated based on national guidelines (Percentage) 2 Number of designated laboratories 07-Apr-2020 1.00 20-Sept-2024 156.00 30-Jun-2025 151.00 The end target for this indicator was with COVID-19 diagnostic capacity revised in accordance with the current (Number) testing strategy. At the start, COVID-19 test was done at the National Reference Laboratory (NRL) using PCR. Overtime, with the availability of Rapid tests, all public hospitals (8 referral hospitals, 8 provincial hospitals and 39 district hospitals) and 100 private health facilities countrywide were engaged to provide rapid tests. 3 Proportion of designated healthcare 07-Apr-2020 20.00 20-Sept-2024 100.00 30-Jun-2025 100.00 All 56 public hospitals have isolation facilities with isolation capacity capacity for at least 2 cases. Health (Percentage) centers and private health facilities does not have isolation capacity; however, they may avail a holding room where they may keep an identified COVID-19 case before the referral. COVID-19 Vaccine Coverage 4 Percentage of population 18 years 28-Feb-2022 0.00 20-Sept-2024 79.70 30-Jun-2025 56.00 At the end of the vaccination campaign in and above receiving a booster, June 2023, up to 79.7% of the population which is included in the population aged 18 years and above have been targets defined in the national plan, reached with a booster dose. disaggregated by sex (Percentage) 5 Percentage of the population fully 05-Feb-2021 20-Sept-2024 79.90 30-Jun-2025 86.00 Achieved since June 2023. The vaccination vaccinated which is included in the coverage rate is calculated against the priority population targets as total population of the country (estimated No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value defined in the national plan at over 13 million in 2021. As of February disaggregated by sex, age group and 2024, 79.9% of the population (equivalent location (Percentage) to 10.8 million people) have received at least two doses; 6 Number of doses of COVID-19 29-Jan-2021 0.00 20-Sept-2024 3,601,440.00 30-Jun-2025 6,000,000.00 Achieved since June 2023. A total of 3.6 vaccine procured with Project million doses were procured with World funding (Number) Bank funding and they were fully delivered and deployed. Given that the country received from multiple sources enough doses to reach the national target, no more vaccines will be procured with World Bank funding. The balance from the vaccine procurement sub-component has been allocated to CERC. Therefore, this indicator is marked as completed. Intermediate Results Indicators by Components No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value Component 1: Case Detection, Confirmation and Contact Tracing 7 Number of laboratory staff trained 07-Apr-2020 0.00 20-Sept-2024 192.00 30-Jun-2023 50.00 Achieved and completed to conduct COVID-19 diagnosis in June 2023 (Number) 8 Percentage of grievances 20-Oct-2020 0.00 20-Sept-2024 100.00 30-Jun-2025 10.00 The Grievance Redress documented, processed and Mechanism (GRM) was resolved within 30 days established, and the (Percentage) committees were set up to resolve the beneficiary issues across the country. The GRCs have resolved 10 grievances which 7 were solely about awareness raising to explain and remove confusion on the vaccines No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value and the remaining 3 were concerns about not having enough food to eat since COVID-19 put down a lot of their livelihood businesses. The GRCs will continue resolving issues that may arise under the CERC component, and these will be documented and reported. 9 Total tests performed by the 20-Oct-2020 0.00 20-Sept-2024 3,634,311.00 30-Jun-2025 0.00 Completed. 1,877,632 Government facilities, males and 1,756,679 disaggregated by sex (Number) females performed by the public health facilities out of the 5,430,216 tests performed as of September 2022 Time response to COVID-19 10 Proportion of targeted healthcare 07-Apr-2020 20.00 20-Sept-2024 100.00 30-Jun-2023 100.00 All 56 public hospitals (8 facilities with clinical capacity for referral hospitals, 8 COVID-19 patients (Percentage) provincial hospitals and 40 district hospitals) have established at least 2 rooms each for the management of COVID-19 cases 11 Number of health staff trained in 07-Apr-2020 20.00 20-Sept-2024 3,554.00 30-Jun-2023 2,000 Completed since June infection prevention and control 2023 (Number) COVID-19 Vaccine Knowledge, Acceptance, and Safety 12 Number of mass media campaigns 05-Feb-2021 0.00 20-Sept-2024 96 30-Jun-2023 90 on COVID-19 prevention and vaccination (Number) No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value 13 Proportion of serious Adverse 05-Feb-2021 0.00 20-Sept-2024 78.00 30-Jun-2025 95.00 Completed since June events following immunization 2023 (AEFI) reported and investigated, by sex (Percentage) Health System Strengthening 14 Number of people screened for 08-Mar-2021 0.00 20-Sept-2024 3,012,311 30-Jun-2025 300,000.00 During FY23/24, underlying chronic conditions, 3,012,311 out of disaggregated sex and age group 3,741,561 eligible people (Number) (35 years above) were screened during NCDs annual checkup. The screening rate is at 80.75% Check Percentage of targeted hospitals 08-Mar-2021 0.00 20-Sept-2024 100.00 30-Jun-2023 100.00 Completed. Currently, all ISR15 with functioning oxygen therapy 56 public hospitals have system (Percentage) functioning oxygen therapy system Maintaining Essential Health Services during and beyond COVID-19 16 Number of outpatient 24-Mar-2021 18,860,619.00 20-Sept-2024 20,551,614 30-Jun-2025 19,622,500.00 Including 18,227,333 new consultations, disaggregated by OPDs and 2,324,281 old age and sex (Number) OPDs, representing a Per Capita Utilization rate of 1.51 (Total pop. 13,647,218) 17 Number of new acceptors of 24-Mar-2021 238,392.00 20-Sept-2024 303,695 30-Jun-2025 248,023.00 The modern contraceptive modern contraception (Number) prevalence rate (mCPR) was 56% at the end of FY23/24 (according the draft MoH report) 18 Number of deliveries conducted 24-Mar-2021 315,814.00 20-Sept-2024 336,897 30-Jun-2025 328,573.00 According to the draft within the facility (Number FY23/24 MoH report, 99.1% of births were attended by skilled health professionals. No Indicator description Baseline Current value End target Comment Date Value Date Value Date Value 19 Number of pregnant women 24-Mar-2021 0.00 20-Sept-2024 177,035 30-Jun-2025 190,280.00 47.1%, according to the receiving four antenatal care visits draft FY23/24 MoH report (Number 20 Number of infants receiving 24-Mar-2021 345,423.00 20-Sept-2024 330,013 30-June-2023 352,330.00 According to the draft Pentavalent 3 vaccine FY23/24 MoH report, 88.7% of expected infants received Penta3 vaccine Annex 4.1 Procurements in Progress (September 2024) Targeted No Inputs Quantities Procurement Process Beneficiaries 1 Blood glucose test strips 1,725,513 300,000 Delivered and districted to health facilities 2 A1c machine + lipid profile analyzer (point of Delivered and districted to health facilities care)/HbA1C / Lipid profile Analyzer - SD 496 300,000 Biosensor - MultiCare 3 HPV Kits 83,720 300,000 Delivered and districted to health facilities 4 Liquid soap (5l) 1,275 300,000 Delivered and districted to health facilities 5 Acetic acid (500ml) 1,275 300,000 Delivered and districted to health facilities 6 Jik (1l) 1,275 300,000 Delivered and districted to health facilities 7 Ouate/500gr roller 1,020 300,000 Delivered and districted to health facilities 8 Alcool dénaturé (denatured alcohol): 5l 510 300,000 Delivered and districted to health facilities 9 Gauze 1,020 300,000 Delivered and districted to health facilities 10 Bamboo skewers: box of 50 pieces 4,000 300,000 Delivered and districted to health facilities 11 Glycerine: 500ml 510 300,000 Delivered and districted to health facilities 12 Sanitary pads: box of 8 pieces 510 300,000 Delivered and districted to health facilities 14 HBA1C strips/Test Strips - SD Multicare - SD Delivered and districted to health facilities 3,000 300,000 Biosensor - HbA1C - box of 20 15 Lancet/box of 100 pieces 17,255 300,000 Delivered and districted to health facilities 16 Alcohol swab/box of 100 pieces 17,255 300,000 Delivered and districted to health facilities 17 Safety box 24,480 300,000 Delivered and districted to health facilities 18 Gloves/box of 100 pieces 35,000 300,000 Delivered and districted to health facilities 19 Lipid profile test/Test Strips - SD Multicare - SD Delivered and districted to health facilities 4,600 300,000 Biosensor - Lipid profile - Box of 20 Annex 4.2. Status of Oxygen Improvement in the Health Care Provision under World Bank Support (September 2024) Inputs Quantities Status Compressor Tendering process has failed – the tender 1 re-launching is expected end of March 2024 Beds Delivered and distributed to health 204 facilities Distribution and installation of beds 1 Installations were completed Install oxygen piping systems (high flow and low Installations were completed flow systems) in 20 hospitals (including piping, a 7 manifold, compressor, oxygen outlets, vacuum and electricity outlets, etc.) Equip CHUK, CHUB, Kibuye, RMH, Kibungo and Tendering process has failed – tender re- 6 launching is expected end of March 2024 Ruhengeri with oxygen delivery trucks Cylinders (50L) 312 Delivered Oxygen analyzers Tendering process has failed – tender re- 55 launching is expected end of March 2024 Oxygen regulators (high flow) 104 Delivered and installed Concentrators (10 or more LPM) 26 Delivered and installed Pulse oximeters 65 Delivered and installed Consumables (masks, nasal cannula, etc) 1 Delivered Infusion pumps 26 Delivered and installed Syringe pumps 52 Delivered and installed ICU beds for the 20 renovated sites 104 Delivered and installed Patients monitors for the 20 renovated sites 104 Delivered and installed Annex 4.3 Procurement of Nutrition Commodities with GFF-EHS Grant (September 2024) N Commodity/drug Quantities Targeted Procurement status o beneficiaries 1 Therapeutic zinc 319,500 1,591,669 Delivered and distributed to supplementation with Oral Health Facilities Rehydration Solution (ORS) 2 Ready to Use Therapeutic 219,313 31,833 Delivered and distributed to Food (RUTF) Health Facilities 3 Therapeutic milk (F100) 38,585 6,367 Delivered and distributed to Health Facilities 4 Therapeutic milk (F75) 9,183 6,367 Delivered and distributed to Health Facilities 5 Resomal 5,792 6,367 Delivered and distributed to Health Facilities 6 Corn Soya Blend (CSB+) 455,000 143,250 Delivered and distributed to Health Facilities 7 Ongera 410,056 526,109 Delivered and distributed to Health Facilities 8 Iron/folic acid 7,025,750 356,700 Delivered and distributed to supplementation Health Facilities 9 Urine Pregnancy Test 54,588 356,700 Delivered and distributed to Health Facilities 1 Hemoglobin 201 90,120 356,700 Delivered and distributed to 0 Health Facilities 1 Hemoglobin 301 88,100 356,700 Delivered and distributed to 1 Health Facilities 1 Gloves 143,000 60,000 Delivered and distributed to 2 Health Facilities TOTAL 3,798,762 Annex 5 Field visit, September 17-18, 2024 On September 17th, 2024, a field visit of 2 days was conducted to assess the progress of the Covid-19 ERP CERC activities. A joint mission with relevant stakeholders including RBC, REMA, MINEMA, District officials and the World Bank Group visited 3 districts; Nyabihu, Rubavu and Rutsiro to assess the effectiveness of the interventions and identify bottle neck and areas for improvement. This report summarizes the mission. NYABIHU Nyabihu is in the Western Province comprising of 12 sectors with a population of 319,047 according to the latest census report (NISR, 2022). The team arrived at the Nyabihu district office where a meeting was held with the Vice Mayor in charge of Social Affairs Mr. Simpenzwe Pascal. In the meeting the Vice Mayor thanked the World Bank and Government officials for their role and commitment to aiding the situation and ensuring effective implementation. Mr. Simpenzwe reiterated that although progress has been made, Nyabihu continues to face challenges with unpredictable weather patterns and climate disasters. Nyabihu is among the 5 intervention districts affected by the landslides of May 2023. The district experienced heavy rains and landslides that claimed the lives of 20 people, and the loss of 100 livestock. 836 families were affected by the disaster. 189 homes were destroyed beyond repair and 340 homes were partially damaged. An assessment carried out by MINEMA identified 304 families situated in high-risk zones. So far, 117 family homes have been rehabilitated. The district continues to work in close collaboration with MINEMA to map out high risk areas and move families to safer zones. A main challenge in the construction of the homes is the transportation of raw materials to building sites. Nyabihu like most Western Provinces has a terrain consisting mostly of hills and valleys. There are households built on top of hills making classifying themselves as high risk. The new housing units showed to have strong foundations to resist landslides, satisfying occupants and providing them relief. According to district officials the sites take on average 3 weeks to construct and materials are readily available. An evacuation site was identified in Kabyaza but is pending land acquisition. A definitive timeline has not been given by district officials. The team later visited Bigogwe Health Center which was recently medicalized. The HC specializes in maternal and antenatal care with specialization in performing c-sections for women with high- risk pregnancies. The medicalization of the center occurred as the district referral hospital was unable to cope with the health demands of the population, particularly women with high-risk pregnancies. Bigogwe health center also incorporated an NCD unit to deal with rising cases of asthma, diabetes and hypertension in Nyabihu’s population. However, the unit faces challenges as they state that there are not enough health care providers and specialists in the NCD field to deal with the health demand. It was also observed that the head nurse of the unit was using traditional pen and book to record patient information exhibiting a strong need for digitalization of health systems. A member from the World Bank safeguard team was present during the visit and questioned health staff on the waste management disposal of the health center. The doctor informed that the premise does not use color coded bags for infectious waste but instead use boxes, this raised concerns amongst as the protocol on infectious waste is not quite clear. Secondly, the health center uses private vehicles to transport all waste to sites that will burn them. This also raises concerns about standard operational procedures in rural health centers. Their internal SOP system tend to be weak. RUBAVU Rubavu is situated in the Western Province bordering the DRC and has a population of 546,683 (NISR, 2022). Rubavu like most Western Provinces faces climate disasters such as floods and landslides. After the 2023 landslides district officials and MINEMA identified 820 families that needed new homes, and 324 houses to be built for victims who already owned land. District officials said that unlike the other 5 districts Rubavu faces heavy floods every four years in addition to the landslides. This is because Rubavu is located next to the Sebeya river that overflows during the rainy season. District officials often find themselves dealing with occasional flooding. Rubavu is also close to the Nyiragongo volcanoes making the area highly susceptible to earth tremors. Upon meeting with the Mayor of Rubavu district, Mr. Prosper Mulindwa, the team were shown 2 sites. One home that was rebuilt (exhibit 1) and an evacuation site (exhibit 2). The evacuation site is owned privately, and the district has been urged to expropriate the land and has not yet done so. This has caused significant delays in the Project. There was also infrastructure that was damaged during the landslides that has not been repaired; WASAC tanks were obstructed making it hard for residents to access clean water. The Kabiriza site requires permanent infrastructures such as water tanks and public toilets and can be used by the district even in cases where there are no natural disasters. There is no good justification as to why the district has not acquired the site in a timely manner. Exhibit 2: Evacuation site in Kabirizi, Rubavu Exhibit 1: House rebuilt for a resident in Rubavu RUTSIRO Rutsiro is a district located in the Western Province, bordering lake Kivu. Rutsiro has a population of 369,180 (NISR,2022). The district is known for its hilly terrains and susceptibility to food shortages as a result. It is among the 5 districts affected by the floods in May of 2023. The team met with the Mayor of Rutsiro Ms. Dative Kayitesi to tour and assess Kivumu Health Center. The health center has been selected as a priority center to be medicalized, since it is one of the most active centers in Western Province serving a population of 33,000 in Rutsiro and parts of Rubavu. The health interventions assessed included stunting prevention, nutrition services, maternal care, antenatal care and treatment of NCD’s. The Western and Northern provinces of Rwanda have statistically shown to have high rates of stunting. Kivumu offers nutritional services to mothers and children. The team visited the maternal care unit currently being supervised by a midwife. The services include screening for urinary and sexually transmitted infections for both partners and identifying potential high-risk pregnancy. The center screens for LPL and syphilis among women and partners and the rates show them to be higher than those of HIV. Syphilis is found in 3/100 patients whereas HIV is 1/100. The center is also one of the centers identified by the MOH to carry out a nutritional service that provides multi micronutrient supplements to pregnant women. It is a pilot project in 7 districts, Rutsiro being one of them. The center experiences 72 new cases of antenatal care a month with only 2 available midwives. This is a major concern as it highlights a need for additional human resource support for both midwives and nurses. The facility is struggling to cater to the antenatal demands of the district and would largely benefit from additional staff. The NCD’s unit is similarly overwhelmed by patients with a limited number of staff to cater. The unit has advanced NCD care by paying home visits to patients with moderate to severe hypertension and diabetes. The center has asked the WB and district officials to provide more ambulances to better reach patients, and to fully digitalize the center for better tracking of health information systems. The center needs an upgrade before it can be fully medicalized. The lead doctors also stated that Rutsiro can largely benefit from a social behavior change campaign on food and nutrition to better educate residents. Annex 6. House rehabilitation: monitoring of progress September 2024 to June 2025. District / Sector Phase 1 Sept.24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Total