The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) REPORT NO.: RES37294 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF RWANDA STUNTING PREVENTION AND REDUCTION PROJECT APPROVED ON FEBRUARY 28, 2018 TO MINISTRY OF FINANCE AND ECONOMIC PLANNING HEALTH, NUTRITION & POPULATION AFRICA Regional Vice President: Hafez M. H. Ghanem Country Director: Carlos Felipe Jaramillo Global Practice Director: Muhammad Ali Pate Practice Manager/Manager: Ernest E. Massiah Task Team Leader: Miriam Schneidman The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) ABBREVIATIONS AND ACRONYMS AARR Average Annual Rate of Reduction AIDS Acquired Immune Deficiency Syndrome ASM Agent de Santé Maternelle [Maternal Health Agent] BCC Behavior Change Communications CBO Community Based Organization CFSVA Comprehensive Food Security and Vulnerability Analysis CHW Community Health Worker CIAT International Center for Tropical Agriculture CIP International Potato Center CPR Contraceptive Prevalence Rate DA Designated Account DHS Demographic and Health Survey DPEM District Plans to Eliminate Malnutrition DPs Development Partners ECD Early Childhood Development EKN Embassy of the Kingdom of the Netherlands GDP Gross Development Progress GFF Global Financing Facility GRS Grievance Redress Service HC Health Centre HIV Human Immuno-Deficiency Virus HMIS Health Management Information System ICB International Competitive Bidding IDA International Development Association IEC Information, Education, and Communication IFA Iron/Folic Acid IFC International Finance Corporation IFI International Financial Institutions IFPRI International Food Policy Research Institute IFMIS Integrated Financial Management Information System IPF Investment Project Financing IYCF Infant and Young Children Feeding JAPEM Joint Action Plan to Eliminate Malnutrition KPIs Key Performance Indicators M&E Monitoring and Evaluation MCCH Maternal, Child and Community Health MDGs Millennium Development Goals MDTF Multi-Donor Trust Fund for Achieving Nutrition Impact at Scale MIGEPROF Ministry of Gender and Family Promotion MICS Multiple Indicator Cluster Survey MINAGRI Ministry of Agriculture and Animal Resources The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) MINALOC Ministry of Local Government MINECOFIN Ministry of Finance and Economic Planning MNP Micronutrient Powders MoH Ministry of Health MoU Memorandum of Understanding MWMP Medical Waste Management Plan NCB National Competitive Bidding NFNCS National Food and Nutrition Coordination Secretariat NGO Non-Governmental Organization NIRP National Independent Review Panel OAG Office of the Auditor General ORS Oral Rehydration Solution PBF Performance Based Financing Program PDO Project Development Objective PIM Project Implementation Manual PNC Postnatal Checkup PPSD Project Procurement Strategy for Development PRAMS Procurement Risk Assessment and Management System PSC Project Steering Committee QCBS Quality and Cost-Based Selection RAB Rwanda Agriculture Board RBC Rwanda Biomedical Center RPPA Rwanda Public Procurement Authority SBDs Standard Bidding Documents SDG Sustainable Development Goal SDR Special Drawing Rights SPIU Single Project Implementation Unit SSP Strengthening Social Protection STEP Systematic Tracking of Exchanges in Procurement SUN Scaling Up Nutrition UN United Nations UNICEF United Nations Children’s Fund USAID United States Agency for International Development VAD Vitamin A Deficiency WASAC Water and Sanitation Corporation Ltd WB World Bank WFP World Food Program WHO World Health Organization The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) BASIC DATA Product Information Project ID Financing Instrument P164845 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 28-Feb-2018 30-Apr-2023 Organizations Borrower Responsible Agency MINISTRY OF FINANCE AND ECONOMIC PLANNING Rwanda Biomedical Center Project Development Objective (PDO) Original PDO The proposed Project Development Objective (PDO) is to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-61870 28-Feb-2018 07-Mar-2018 05-Jun-2018 30-Apr-2023 25.00 4.40 19.96 TF-A6567 28-Feb-2018 07-Mar-2018 05-Jun-2018 30-Apr-2023 20.00 2.69 17.31 TF-A6783 29-Jan-2018 07-Mar-2018 05-Jun-2018 31-Dec-2021 10.00 3.85 6.15 The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Project Status 1. The Stunting Prevention and Reduction Project (SPRP) continues to enjoy high-level political commitment and strong multisectoral coordination under the leadership of the National Early Childhood Development Program (NECDP). The SPRP has been under implementation for over one year and progress towards achieving the Project Development Objective is steady. Progress has picked up in recent months and disbursements are on track with roughly US$11 million or 20 percent of the US$55 million disbursed to date. The latest ISR archived in May 2019 rated both progress on implementation and towards achievement of the PDO as “satisfactory”. 2. The main achievements to date are as follows: (i) finalizing the National Integrated ECD, Nutrition and WASH Social and Behavior Change Communication Strategy (2018-2024) and receiving endorsement of both the NECDP and MoH senior management; (ii) initiating a reform of the Community Health Worker (CHW) program (e.g. introducing a certification scheme; developing and providing training on a new integrated curriculum); (iii) mobilizing and empowering the 13 target districts to carry out activities at local level through funding of the District Plans to Eliminate Malnutrition; (iv) finalizing guidelines for the early childhood development (ECD) interventions and conducting training of trainers for ECD caregivers, district officers and friends of the family (‘Inshuti z’Umuryango’); (v) initiating procurement of WASH materials; (vi) financing of high impact health and nutrition interventions through the national Performance-based Financing program; and (vii) getting the baseline survey for the impact evaluation underway, with a firm recently contracted by the World Bank. Rationale for Restructuring 3. The rationale for restructuring is three-fold. First, Rwandan authorities expressed concerns with the pervasive levels of food insecurity which can impede progress on reducing stunting. According to the 2018 Comprehensive Food Security and Vulnerability Survey, almost 20 percent of all households are food insecure. Food insecurity has risen since 2015 in the13 target districts, and are very high in some districts, including Rutsiro (49 percent), Ngororero (41 percent), and Kayonza (33 percent). Similarly, in 2018, 20 percent of households had borderline food consumption and 4 percent had poor food consumption, which reflects an extremely unbalanced diet. While food consumption improved in 17 districts since 2015, it seriously deteriorated or remained inadequate in many of the target districts. In 2018, 40 percent of households, compared to 27 percent in 2015, reported having experienced at least one shock or an uncommon situation during the last 12 months that affected its ability to provide food for itself or eat in a manner it is accustomed to. Second, the government underscored the importance of identifying other strategies for accelerating progress towards stunting reduction, and shared preliminary results from a mid-line evaluation of a program that provides a fortified blended food product (FBF) that appears to reduce stunting more rapidly. Third, the government team explained that funding for some activities initially planned under the SPRP will now be provided through other ministries, agencies, and home-grown solutions, hence freeing up some resources. 4. The proposed restructuring agreed upon with Rwandan authorities is based on the following principles: (i) maintaining the integrity of the original design that was based on best buy interventions; (ii) protecting critical areas of the project that require catalytic external funding, such as the CHW program, behavior change communications, district- level convergence agenda; and M&E; (iii) adopting a gradual and phased approach to the provision of FBF, which involves monitoring, measuring impact, making course corrections, and scaling up what works; and (iv) limiting the restructuring to the IDA credit that has a large undisbursed balance and several activities now covered by the government. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) 5. The proposed restructuring will build and improve on the ongoing FBF national program supported by the government and several development partners (e.g. CHAI, DFID, WFP). Based on technical discussions with key stakeholders, it was noted that the current FBF program aims to enhance impact through the large-scale provision of high- quality complementary foods to the poorest and most vulnerable households (i.e. ubudehe 1). The current program has several strengths, including: (i) a supply chain that is working well, providing the FBF to nearly 500 health centers nationwide; (ii) limited leakages in terms of the sale of the product on the local market; and (iii) strong policy, programmatic and M&E support from development partners. 6. Building and leveraging on these investments, the government now aims to further improve the effectiveness and impact of the program by: (i) increasing the ration sizes to bolster coverage; (ii) strengthening the enrollment process through automatic enrollment of eligible pregnant lactating women and children 6-23 months, using multiple entry points (e.g. antenatal, maternity and vaccination services); (iii) outsourcing the delivery model through the NECDP, as this is considered to be less costly; and (iv) raising awareness among beneficiaries and providers on the appropriate quantity of FBF to prepare per day; how to prepare and serve FBF; how to minimize intra-household sharing; and why it is important to maintain current breastfeeding practices. The Bank team has reviewed and endorsed these strategies that will be partly funded through the proposed restructuring. 7. The restructuring will also involve the establishment of a Contingency Emergency Response Component (CERC). This is triggered by the ongoing Ebola outbreak in neighboring Democratic Republic of Congo (DRC) and the elevated risk of cross border transmission, considering the porous nature of borders, cross border economic activity, and widespread population movements. The Ministry of Health, supported by partners, has developed and is implementing an EVD preparedness and contingency plan to strengthen outbreak preparedness for prevention, early detection, response and rapid containment of potential cases. While there have been several alerts and suspected cases, there are no EVD confirmed cases in Rwanda. Nevertheless, Rwanda continues to have important gaps in outbreak response capacity and in financing. The latest Joint External Evaluation score for Rwanda was 59 percent (average score of 2.9 on the 5.0 scale), which illustrates the persistent gaps that need to be addressed. The inclusion of the CERC will allow the country to respond quickly and efficiently. II. DESCRIPTION OF PROPOSED CHANGES 8. Component and Cost. The proposed changes involve the introduction of a new sub-component under Component 1 (Prevention of Stunting at Community and Household Level) to support the government’s FBF program in the 13 target districts under the project. The US$8 million equivalent FBF sub-component provides an opportunity to get more evidence on two critical aspects of the program that will improve effectiveness and equity, namely: (i) testing higher rations of FBF for children 6-23 months; and (ii) expanding support to pregnant and lactating women in ubudehe 2 households (i.e. the program currently supports only ubudehe 1 households). To this end, the project will fund the procurement of goods (FBF), consulting (i.e. recruitment of technical experts) and non-consulting services (i.e. logistical support), and training related to sensitization/awareness raising on proper utilization of FBF. 9. The proposed restructuring also involves inclusion of a CERC as a new Project component (with a US$0 allocation) to support a rapid response to disease outbreaks, as per the government’s request to the Bank to access the Pandemic Emergency Financing Facility. The objective of this component is to improve Rwanda’s response capacity in the event of an emergency, following the procedures governed by Bank Policy on Investment Project Financing, paragraphs 12-14, regarding “Projects in Situations of Urgent Need of Assistance or Capacity Constraints.” There is a moderate to high probability that during the life of the project the country may experience a natural or man-made disaster or crisis, including a disease outbreak of public health importance or other health emergency, which has caused, or is likely to imminently The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) cause, a major adverse economic and/or social impact. In anticipation of such an event, the CERC provides Rwanda with rapid reallocation of undisbursed funds from other project components following an emergency to address immediate financing needs to mitigate, respond and recover from the potential harmful consequences arising from such emergency. The availability of immediate financing is critically important in: (a) supporting the first response; (b) helping to coordinate the early recovery phase; and (c) bridging the gap to longer term recovery and reconstruction phases. 10. The CERC Annex to the Operations Manual (CERC-OM) lays out the general provisions for activating and implementing the CERC. Disbursements will be made against an approved list of goods, works, and services required to support crisis mitigation, response and recovery purposes. A new disbursement category will be added for expenditures related to emergency response activities. 11. Technical Analysis. The Bank team carried out an analysis of the technical merits of the FBF sub-component and concluded that it was justified, in light of the: (i) persistent and pervasive nature of food insecurity in the 13 target districts; (ii) growing global evidence that when given during pregnancy and used consistently, fortified supplementary foods have shown to have positive effects on maternal health and pregnancy outcomes, including preventing anemia and iron deficiency among mothers, increasing mean birthweight by approximately 60-73 grams, and increasing birth length and reducing pre-term delivery (Yang, Z. Huffman SL., 2011. Review of fortified food and beverage products for pregnant and lactating women and their impact on nutritional status); and (iii) importance of testing higher ration sizes to enhance impact. Finally, the strong government commitment and complementary support from other development partners augur well for strengthening the institutional framework, generating new evidence of what works to reduce stunting at an accelerated rate, and bolstering the probability of sustainability. 12. The Bank team agreed with the government on the theory of change/results chain for the FBF sub-component which depicts the activities to be supported, along with expected outputs and outcomes (Annex I). Finally, the technical analysis included a review of key issues and risks associated with the FBF program and systematic identification of mitigation measures, as well as inclusion of key program indicators to monitor progress. These include issues related to the: efficiency of the supply chain and distribution system; systematic utilization and consumption of the FBF by key beneficiaries; and program sustainability, including government financing, which is part of the Bank’s ongoing policy dialogue with Rwandese authorities with a review of allocative efficiency currently ongoing (Annex II). Similarly, the inclusion of the CERC is deemed technically sound, as it will allow Rwanda to rapidly access undisbursed IDA funds to address immediate financing needs in the event of a crisis and/or emergency. 13. Reallocation between Disbursement Categories. To facilitate the introduction of the FBF sub-component, an amount of 5.62 million SDR (US$8 million equivalent) has been reallocated from Category 4 (Goods, non-consulting services, training and incremental operating costs under Part 1 (iv) and (v) and Part 3 (iii) of the project to a new Category 6 (Goods) under Part 1 (vii) of the project (FBF sub-component). 14. New Disbursement Category. A new disbursement category with a US$0 allocation has been established for CERC. Disbursements under the CERC will be contingent upon the fulfillment of the following conditions: (i) the Borrower has determined that an eligible crisis or emergency has occurred and the Bank has agreed and notified the Government; and (ii) the Borrower has prepared and adopted the CERC-OM. For the purposes of disbursement, the CERC-OM would include a menu of eligible expenditures; i.e. either against a positive list of critical goods and/or against the procurement of works, and consultant services required to support the immediate response and recovery needs. Emergency expenditures required for the CERC will be procured in accordance with the procurement methods and procedures set forth in the CERC-OM. 15. Procurement. As part of the restructuring, the Project Procurement Strategy for Development (PPSD) of the project has been updated by the government. The updated PPSD includes a provision for the procurement of Fortified Blended Food (FBF) from the Africa Improved Foods (AIF) corporation in Kigali for an amount up to US$8 million using the Direct Contracting (DC) Procedure. The Borrower provided a justification for DC as part of the PPSD. The Bank reviewed The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) the proposed procurement of Fortified Blended Food from the Africa Improved Food Ltd, following Direct Contracting and noted that there are two more suppliers who produce a similar FBF. To avoid disruption in the supply of this important food supplement and based on the justification provided, the Bank agreed to procure the product for the first 12 months (considering procurement and supply lead time of 9 months) following the DC procedure. For future procurement of FBF, the SPIU has been advised to initiate a competitive procurement process with agreed technical specifications. 16. The IFC has a stake in AIF and we have consulted with the inter-institutional COI committee. The advice the team received is that there might be a perception but probably not an actual COI. The Regional Directors reviewed the matter and provided the following guidance: (i) IFC’s involvement in AIF precedes the Bank’s engagement with the entity (i.e. IFC has been supporting the expansion of a private sector entity, working with national and foreign investors while the WB will now procure FBF from the factory to support the government’s stunting reduction program, in line with the national strategy); (ii) the roles and responsibilities of AIF and the activities to be supported under the Bank-funded project have been reviewed and there does not appear to be an actual conflict of interest, given the strong direct contracting justification provided by the government, and agreed by the Bank for the first 12 months, underscoring the need for continuity in the supply and reasonable value for money; (iii) going forward, the potential inter-institutional COI is being handled by a proposed joint WB/IFC working group to be chaired by management with a view to coordinate the dialogue with the Government on the process for the two reviews and the discussion on their findings and next steps. 17. Results Framework. The Results Framework has been revised to include two additional indicators related to the FBF sub-component: (i) proportion of distribution sites with stock outs during the past three months; and (ii) proportion of ubudehe 1 and ubudehe 2 pregnant and lactating women reporting consumption of FBF in the last 24 hours. The current impact evaluation will be amended to measure the impact of the FBF intervention on children (by comparing outcomes for children in ubudehe 2 households with that of children in ubudehe 3 households from the 13 target districts). 18. In addition, beyond the current evaluation, two key impacts of the FBF intervention to be monitored and evaluated are: (i) improved nutritional status of pregnant women; and (ii) improved birth outcomes (i.e. lower probability of having a low birth weight baby). The Bank is also supporting the government to develop a sound methodology for evaluating the impact, cost and cost-effectiveness of the FBF intervention, which would inform the scale up in subsequent years. The Bank has mobilized additional resources for analyzing behavioral issues that facilitate or impede consistent use of appropriate FBF portions and determining how to lower the cost of adherence to FBF and other beneficial feeding practices. This qualitative study will promote, and measure behavior change related to the FBF product and complementary feeding practices more generally (e.g. acceptance of product; any perverse effects on breast feeding patterns; risk of substitution of local foods; changes in social norms regarding FBF consumption, as well as other nutrition practices; habit formation; long-term behavior change). Finally, the restructuring also involves several changes in the original set of intermediate and outcome indicators, as included in the data sheet. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) Annex I: FBF Theory of Change/Results Chain INPUTS ACTIVITIES OUTPUTS OUTCOME IMPACT S FBF along with Pregnant woman  Pregnant women  Optimal appropriate consumes attain to the intrauterine counseling is provided appropriate necessary daily growth to pregnant women quantities of FBF caloric intake  Improved birth FBF along with  Improved outcomes appropriate Lactating woman nutrition status  Increased counseling is provided consumes of pregnant availability of to lactating women appropriate woman nutrients in FBF along with quantities of FBF to  Lactating women breastmilk appropriate achieve the necessary attain the  Improved counseling is provided daily caloric intake Decreased likelihood necessary daily nutrient intake to caregivers of of stunting caloric intake for children 6-23 months  Improved breastfeeding old Child is fed adequate nutrition status child quantities of FBF and of pregnant  Improved at the suggested woman intake of frequency  Children achieve macronutrients adequate and quantity and micronutrients frequency of among young feeding children The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) Annex II: Technical Analysis of FBF Sub-Component: Main Issues & Risks, Mitigation Measures & Key Program Indicators Main Areas Key Issue/Risk Mitigation Measure Main Program Indicator Supply chain & distribution -Stock outs of FBF -Maintain coverage of ‘% of distribution sites with distribution centers and stock outs in the last 3 introduce/strengthen months systems for efficient management of supplies -Diverted products -Mobilize district authorities -% of product diverted to conduct periodic spot checks in local markets and to educate the public about the risk of diversion -Contaminated products -Maintain high quality -% of reported cases of standards and regulatory contamination capacity Utilization & consumption -Inaccurate -Provide training/counseling -% caretakers reporting understanding of FBF to caregivers and to accurate understanding of pregnant and lactating serving size, portions, women about appropriate storage and preparation -Poor targeting of feeding practices; intra- -% of ubudehe 1/2 beneficiaries (leakages at household consumption; pregnant and lactating household level) and maintaining high levels women reporting of breast feeding consumption of FBF in the last 24 hours -Inadequate - -Average quantities of FBF consumption of FBF reported as consumed by pregnant and lactating women in ubudehe 2 households Program sustainability -Government financing -Secure government -% financing of FBF of program is reduced commitment that its program contribution will be maintained or increased over the course of the project -Absorption of critical -Agree on a plan for -% personnel recruited who personnel is lagging absorbing key personnel are absorbed The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) I. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Procurement ✔ Technical Analysis ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ APA Reliance ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Prevention of Component 1: Prevention of Stunting at Community and 35000000.00 Revised Stunting at Community and 35000000.00 Household Levels Household Levels Component 2: High-impact Component 2: High-impact 14500000.00 No Change 14500000.00 Health and Nutrition Services Health and Nutrition Services Component 3: Monitoring and Component 3: Monitoring and Evaluation, and Program 5500000.00 No Change Evaluation, and Program 5500000.00 Management Management 0.00 New CERC 0.00 55,000,000. TOTAL 55,000,000.00 00 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-61870-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: Gds,NonCS,CS Pt 1(i) 710,000.00 0.00 710,000.00 25.00 25.00 iLap Category Sequence No: 2 Current Expenditure Category: Gds,NonCS,CS&Trg Pt 1(ii) 1,410,000.00 0.00 1,410,000.00 0.00 0.00 iLap Category Sequence No: 3 Current Expenditure Category: Performance Based Pymts Pt1iii 4,450,000.00 0.00 4,450,000.00 100.00 100.00 iLap Category Sequence No: 4 Current Expenditure Category: Gds,NonCS,CS,Tr,OC Pt1iv&v &3iii 9,620,000.00 0.00 4,000,000.00 100.00 100.00 The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) iLap Category Sequence No: 5 Current Expenditure Category: Gds,NonCS,CS&Trg Pt1(iv) 1,410,000.00 0.00 1,410,000.00 0.00 100 iLap Category Sequence No: 6 Current Expenditure Category: Gds-FBF 0.00 0.00 5,620,000.00 100 Total 17,600,000.00 0.00 17,600,000.00 . The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) . Results framework COUNTRY: Rwanda Rwanda Stunting Prevention and Reduction Project Project Development Objectives(s) The proposed Project Development Objective (PDO) is to contribute to the reduction in the stunting rate among children under five years of age (with a focus on those under two) in the targeted districts. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target To contribute to reduction in the stunting rate among children under five in the target districts Indicator 1a: Percentage of children under 5 years with height- 43.60 32.00 for-age z-score below -2 standard deviations (Percentage) Rationale: 1. The indicator was revised to add definition, data source, frequency, and responsibility for data collection. Action: This indicator has been Revised 2. Corrected baseline and target values. Previous values reflected data for children under 2. Indicator 1b: Percentage of children under 2 years with height- 37.10 27.20 for-age z-score below -2 standard deviations (Percentage) Rationale: Action: This indicator has been Revised The indicator was revised to add definition, data source, frequency, and responsibility for data collection. Indicator 2: Percentage of children 6-23 months old who are fed 22.90 50.00 a diverse diet (Percentage) Action: This indicator has been Revised Rationale: The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target The indicator was revised to add definition, data source, frequency, and responsibility for data collection. Indicator 3: Percentage of women who attended 4 or more ANC 41.00 55.00 visits during their most recent pregnancy (Percentage) Rationale: Action: This indicator has been Revised The indicator was revised to add definition, data source, frequency, and responsibility for data collection. People who have received essential health, nutrition, and 0.00 1,660,000.00 population (HNP) services (CRI, Number) Action: This indicator has been Revised Number of women and children who have received basic 0.00 1,660,000.00 nutrition services (CRI, Number) Indicator 4a: Number of children under 5 were beneficiaries 0.00 560,000.00 of project interventions (Number) Rationale: Action: This indicator has been Revised The indicator was revised to add definition, data source, frequency, and responsibility for data collection. Indicator 4b: Number of women of reproductive age (including pregnant and lactating women) who were 0.00 1,100,000.00 beneficiaries of project interventions (Number) Rationale: Action: This indicator has been Revised The indicator was revised to add definition, data source, frequency, and responsibility for data collection. PDO Table SPACE The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Component 1: Prevention of Stunting at Community and Household Levels IRI 1: Percentage of children at risk of stunting identified at the 0.00 75.00 health center receiving follow up visits by CHWs (Percentage) Rationale: After discussions between the World Bank project team and the Government of Rwanda counterparts at the Rwanda Biomedical Center, it was agreed that this is a complex indicator which should be dropped from the results framework Action: This indicator has been Marked for Deletion because the two-way communication system necessary to facilitate the tracking of follow-up of at-risk children was yet to be implemented. It was agreed that once the communication system has been established, this output should be tracked as part of the project M & E. IRI 2: Percentage of home-based ECD centers with satisfactory 0.00 80.00 scores on quality score card (Percentage) Rationale: Action: This indicator has been Revised Added definition, data source, and responsibility for data collection. IRI 3: Number of parenting groups created and functional 0.00 0.00 (positive deviance) (Number) Rationale: Action: This indicator has been Marked for Deletion Added definition, data source, frequency, and responsibility for data collection. IRI 4: % of CHWs who received a quarterly supportive supervision 40.00 80.00 visit from HC (Percentage) Rationale: Action: This indicator has been Revised Added definition, data source, frequency, and responsibility for data collection. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target IRI 5: Percentage of pregnant women who attended the first ANC 40.00 70.00 visit during the first trimester (Percentage) Rationale: 1. Added definition, data source, frequency, and responsibility for data collection. 2. Rwanda Biomedical Center revised the baseline based on HMIS data for the 13 project districts. The original Action: This indicator has been Revised baseline was based on DHS estimates. The baseline was revised from 56 percent to 40 percent. Based on HMIS quarterly trend, RBC projected a year 1 target of 46 percent. An annual increase of 6 percentage points was assumed, for a final target of 70 percent. IRI 6: Percentage of pregnant women with anemia (Percentage) 2.00 1.00 Rationale: 1. Added definition, data source, frequency, and responsibility for data collection. 2. The baseline was revised by Rwanda Biomedical Center based on estimates from the HMIS for the 13 project Action: This indicator has been Revised districts. The baseline was previously based on DHS data, and was revised from 21.9 percent to 2 percent. The target was revised from 15 percent to 1 percent. IRI 7: Percentage of participants at CHW education sessions surveyed who demonstrate knowledge of proper care, feeding, 0.00 50.00 and WASH practices (Percentage) Rationale: Action: This indicator has been Revised Added definition, data source, frequency, and responsibility for data collection. IRI 8: Percentage of children 6-23 months old receiving 0.00 90.00 micronutrient powders (Percentage) Rationale: Action: This indicator has been Revised Added definition, data source, frequency, and responsibility for data collection. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target IRI 9: Percentage of children under two with diarrhea treated 0.00 50.00 with ORS and zinc. (Percentage) Rationale: 1. Based on discussions with Rwanda Biomedical Center, revised the indicator name so as to simplify it. As now defined, this required data can be gathered from HMIS. Action: This indicator has been Revised 2. Added definition, data source, frequency, and responsibility for data collection. IRI 10: Number of Ubudehe 1 households with improved latrines 0.00 5,500.00 (from project interventions) (Number) Rationale: 1. Added definition, data source, frequency, and responsibility for data collection. 2. Updated target to reflect reallocation of resources as part of the restructuring. Rwanda Biomedical Center Action: This indicator has been Revised indicated that material has already been procured to refurbish approximately 5,500 latrines for ubudehe 1 households. No additional materials for this purpose will be procured. IRI 11: Number of districts with satisfactory ratings on the DPEM 0.00 13.00 activity scorecard (to be developed) (Number) Rationale: Action: This indicator has been Revised Added definition, data source, frequency, and responsibility for data collection. Component 2: High-impact Health and Nutrition Services IRI 12: Percentage of children under 5 with height measured and 0.00 75.00 recorded at health facility (Percentage) Action: This indicator has been Revised Rationale: The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target 1. Revised indicator name to reflect availability of data. The previous indicator name included a quality component ('correctly measured') which, after discussion with Rwanda Biomedical Center, would be very difficult to collect and currently no system in place to assess the quality of measurements. 2. Added definition, data source, frequency, and responsibility for data collection. IRI 13: Percentage of CHWs with no stock out of Zinc for diarrhea 0.00 100.00 treatment. (Percentage) Rationale: 1. The name of the indicator was revised to reflect availability of data. While stock outs are tracked at the district hospital and pharmacy levels, health center level stock out is not systematically tracked. However, CHWs report Action: This indicator has been Revised stock outs of commodities, and this data can be sourced from their monthly reports. 2. Added definition, data source, frequency, and responsibility for data collection. IRI 14: Percentage of women of reproductive age who are new 0.00 60.00 acceptors of modern contraceptives (Percentage) Rationale: 1. Revised indicator name to reflect how data is collected. The original indicator referred to new users but, according to Rwanda Biomedical Center, this indicator would be capturing women who switched methods. The Action: This indicator has been Revised revised indicator captures women who have newly started using a modern method. 2. Added definition, data source, frequency, and responsibility for data collection. IRI 15: Percentage of fortified blended food (FBF) distribution 0.00 100.00 centers with no stock outs in the previous quarter. (Percentage) Rationale: The restructuring involves the inclusion of the provision of FBF to pregnant/lactating women, and this is intended to track Action: This indicator is New availability at distribution sites. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target IRI 16: Percent of eligible pregnant and lactating women from ubudehe 1 & 2 households who consumed FBF in the past 24 0.00 80.00 hours. (Percentage) Rationale: The restructuring involves the inclusion of the provision of FBF to pregnant/lactating women, and this is intended to track Action: This indicator is New consumption by pregnant women. IRI 17: Percentage of children 6-23 months old who consumed 0.00 75.00 FBF in the past 24 hours (Percentage) Rationale: FBF will be included in project interventions as part of the restructuring. As part of monitoring effective implementation, it Action: This indicator is New will be important to ensure utilization of the complementary foods by targeted children. Component 3: Monitoring and Evaluation, and Program Management IRI 18: Percentage of participating health facilities that receive satisfactory rating from women and caregivers whose children 0.00 90.00 received nutrition services (Citizen Engagement indicator) (Percentage) Rationale: 1. Added definition, data source, frequency, and responsibility for data collection. Action: This indicator has been Revised 2. Corrected unit of measure (previously as Amount (USD)). IRI 19: Number of peer learning events conducted (within and 0.00 25.00 between districts and sectors) (Number) Rationale: Action: This indicator has been Revised Added definition, data source, frequency, and responsibility for data collection. The World Bank Rwanda Stunting Prevention and Reduction Project (P164845) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target IO Table SPACE The World Bank Rwanda Stunting Prevention and Reduction Project (P164845)