The World Bank Rwanda JSDF - Support to Community Health Workers Project Project Information Document/ Identification/Concept Stage (PID) Public Disclosure Copy Concept Stage | Date Prepared/Updated: 18-Jun-2022 | Report No: PIDC235446 Jun 20, 2022 Page 1 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project BASIC INFORMATION A. Basic Project Data Environmental and Project ID Parent Project ID (if any) Social Risk Project Name Classification Moderate Rwanda JSDF - Support to P175583 Community Health Workers Project Region Country Date PID Prepared Estimated Date of Approval EASTERN AND SOUTHERN Rwanda 18-Jun-2022 AFRICA Financing Instrument Borrower(s) Implementing Agency Public Disclosure Copy Investment Project Ministry of Finance Rwanda Biomedical Financing (MINECOFIN) Center PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 2.76 Total Financing 2.76 Financing Gap 0.00 DETAILS -NewFinEnh1 Non-World Bank Group Financing Trust Funds 2.76 Japan Social Development Fund 2.76 B. Introduction and Context Country Context Rwanda has made substantial progress in reducing poverty levels and increasing agricultural production. The country has consistently outperformed other countries in the East Africa region on many indicators of socio- economic development. With Rwanda’s economy growing at 9.5 percent in 2019, the share of the population below the national poverty line dropped from about 50 to 39 percent during 2011 to 2019. The country’s score on the Global Hunger Index, a composite indicator of undernourishment and child mortality, dropped by nearly 50 percent during 2000 to 2019. These gains in poverty reduction have been accompanied by Jun 20, 2022 Page 2 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project progress on human development, including meeting most of the Millennium Development Goals (MDGs) by 2015. Despite impressive gains in maternal and child survival and some improvement in overall nutrition status, childhood malnutrition rates remain high across the country, and the current COVID-19 pandemic threatens progress made on key health and nutrition indicators. While the Sustainable Development Goal (SDG) target on acute malnutrition (wasting) has already been met, and some declines in chronic malnutrition (stunting) have been recorded, the stunting rate remains stubbornly high at 33 percent (DHS 2020). The age groups most affected by stunting are children from 24 to 35 months of age, with approximately 40.4 percent affected. Socio-economic status plays a large role in malnutrition, with stunting rates significantly higher among the poorest twenty percent of the population (50 percent stunting rate) as compared to the richest (20 percent stunting rate). Stunting increases with age, peaking at 40 percent among children aged 24-35 months. A higher proportion of children in rural areas (36 percent) than urban areas (20 percent) are Public Disclosure Copy affected by stunting, 49 percent of children in the lowest wealth quintile are stunted, as compared with 11 percent of children in the highest quintile (DHS 2020). Rwanda’s Vision 2050 sets an ambitious agenda for improvements in food security and for addressing malnutrition. As stated in Rwanda's National Strategy for Transformation (NST1) 2017–2024, improving food security and addressing malnutrition will contribute to the twin goals of poverty reduction and shared prosperity. There is broad-based recognition that stunting represents an impediment to Rwanda’s aspiration to become a middle-income country, given its long-term negative effects on human capital development. Sectoral and Institutional Context Background of Rwanda’s Community Health Workers (CHW) program The Community Health Workers (CHW) program has made remarkable progress since its inception and contributes significantly to increasing the uptake of essential reproductive, maternal, neonatal, child and adolescent health (RMNCAH) services. When it was first launched in 1995, the program recruited and deployed 12,000 CHWs; as of 2020, that number has nearly quintupled with over 60,000 active CHWs. Four CHWs work in each village of 50 to 150 households: a male-female pair (agents de santé binôme) that focuses on integrated community case management of childhood illnesses, one Animatrice de Santé Maternelle (ASM) who focuses on maternal and newborn health services, and one CHW in charge of health promotion. Together, they are responsible for a comprehensive range of services, including health education, malnutrition screening, family planning, and infectious disease management. A 2016 evaluation found that the CHW program is highly effective in supporting Rwanda’s health system because it absorbs a percentage of the demand for services and creates a platform that complements the formal health sector in delivering a package of preventive and curative services at the village level (Rwanda Ministry of Health, 2016). CHWs are volunteers who receive financial incentives as part of a performance-based financing (PBF) scheme that rewards both quantity and quality of services related to specific health indicators. Since 2006, Rwandese authorities have supported CHW cooperatives, with the Ministry of Health’s Strategic Plan for Jun 20, 2022 Page 3 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project 2013 to 2018 goal to improve delivery and utilization of health services and to strengthen CHW cooperatives through financial and non-financial incentives. Currently there are about 485 CHW cooperatives in Rwanda which are formally registered and legally recognized by the government. CHWs play a vital role delivering health and nutrition services to vulnerable populations in Rwanda, and in identifying and following-up on cases of malnutrition. Specifically, CHWs complement and build on the health care provided by health center workers by expanding coverage of basic services, especially community-based family planning services and treatment of moderate and acute (without complications) childhood malnutrition cases. They are also key for awareness raising and engage in education and training of parents, caregivers, and local leaders on issues of care, feeding, hygiene, and sanitation practices, as well as monitoring progress of different interventions, leading to increased demand for essential services and improved nutrition knowledge. However, issues of retention, service delivery and incentives remain the biggest barriers to fully harnessing the positive impact of CHWs on nutrition in Rwanda. Public Disclosure Copy To promote financial sustainability of the cooperatives, the CHW program has been using a combination of performance-based individual and group incentives. In 2006, a health facility-based PBF strategy was rolled out and in 2009, a community-PBF (c-PBF) strategy was introduced to motivate CHWs. As part of the community PBF scheme, CHWs are evaluated and incentivized based on the delivery of a core set of community health and nutrition interventions. The individual incentives are paid by the Ministry of Health (MoH), while group PBF payments come from the Ministry of Economy and Finance (MINECOFIN) and are channeled directly to the CHW cooperatives. Historically, the PBF incentives were divided with 30 percent going towards individual members and 70 percent going towards the cooperative accounts, in order to increase capital and savings. In 2018, the government reconsidered the 30/70 split, as individual incentives were considered too low to sustain motivation and maintain strong performance of the CHW program. CHWs are now paid 100 percent of their PBF payments from the MoH, and PBF payments to cooperatives come from MINECOFIN as part of district earmarked transfers. PBF payments are done on a quarterly basis, with the amount paid varying for each CHW. The Government of Rwanda (GoR) views the CHW program as critical to improving health and nutrition outcomes among the most vulnerable and hardest to reach. Rwandese authorities have expressed continuous commitment to support and strengthen the program, specifically as it relates to the participation of women. This is reflected through the cross-cutting gender theme in Vision 2020 and in the Second Economic Development and Poverty Reduction Strategy (EDPRS). The new generation of EDPRs - the National Strategy for Transformation (NST1) 2017-2024 -includes a commitment to mainstream gender equity in all national programs, with the goal of increasing female participation in CHW cooperatives. Furthermore, the Community Health Worker Reform in Rwanda Workshop held in December 2018 concluded that there are opportunities for greater impact of the CHW program by addressing key challenges to quality, including in training and recruitment, supervision & mentorship, financial sustainability and data accountability, including among female CHWs; and a 2016 assessment of the CHW program included a recommendation to equip and train more female CHWs to take on leadership roles. Jun 20, 2022 Page 4 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project The cooperative IGAs have substantial potential but are impeded not only by the limited skills of cooperative managers and members but also from lack of access to capital. Findings from the interviews indicate that due to inadequate business knowledge, most CHWs implement their IGAs on a “trial by error” basis with limited diversification, low access to new markets, and poorly designed IGAs, which represent some of the biggest barriers to improving the financial performance of CHW cooperatives. This was demonstrated in some health centers where CHW cooperatives chose certain IGAs, such as selling alcoholic beverages and soft drinks, which according to those interviewed, are non-essential. Rather, they stated that a focus on essential commodities like food or milk could actually generate more revenues for cooperatives while aligning well with the community’s needs. While the majority of IGAs that CHW cooperatives currently engage in are focused on livestock (52.7 percent) and agriculture (20.4 percent), followed by trade (17 percent), house rental (5.7 percent), industrial activities (2.5 percent) and transport (1.7 percent), most of the livestock and agriculture products do not directly benefit the most vulnerable groups. Public Disclosure Copy The policies within which CHW cooperatives operate significantly influence their performance. Although few studies currently exist on this relationship, cooperative members noted that performance was negatively impacted when legislative frameworks were not conducive to cooperative development, and also when local leaders interfered with the management and operations of the cooperatives (such as investment choices). This interference can be damaging especially if taken against the will of the members as it may lead to lower confidence of CHW members towards the program, lack of ownership, and overall poor functioning of the cooperatives. Currently, more than half of CHWs in Rwanda are female, yet their leadership position within cooperatives remains modest – only roughly 20 percent of the cooperatives have female presidents. Despite the commitment by the GoR help women work and gain control over resources, and the strong participation of women in government – Rwanda currently lead the world in the representation of women in Parliament, in the case of leading small business and cooperatives women face various cultural and social barriers. This underrepresentation is similar to other businesses in Rwanda as women face various cultural and social barriers. Although current cooperative guidelines are gender-neutral in terms of membership and access to leadership positions, in practice, several limitations influence a woman’s ability to join and lead cooperatives including lack of access to professional training and financing, and high costs of inputs and materials. This surmounts to a huge loss for the nation and society as a whole, as research shows that improved access to business opportunities for women has significant benefits for their families and communities. Supporting female CHW, therefore, is an important means to contribute to reducing poverty and health problems in Rwanda. CHW cooperatives in Rwanda have the potential to improve the welfare of participating women and their families while fostering medium to long-term sustainability of the CHW program itself. The Government of Rwanda and key development partners view cooperatives as important to the country’s development. In 2004 a national policy was introduced to strengthen the overall cooperative program, and to specifically enhance women’s participation within the cooperatives. The cooperatives serve as a model of solidarity, where members come together to pull resources and carry out IGAs to sustain themselves and their families. Cooperatives and other collective forms of economic and social enterprise are some of the most effective Jun 20, 2022 Page 5 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project ways to improve women’s social and economic capacities in Rwanda, which in turn support and have the potential to improve community and household well-being (International Labor Organization, 2015). Results from the Japan Social Development Fund (JSDF) Seed Funding activities A JSDF seed grant was awarded in 2019 to conduct bottom-up consultations with key stakeholders (CHW cooperative participants, key partners and beneficiaries) regarding the specific needs and opportunities to improve performance of female-led CHW cooperatives to ensure that the JSDF follow-up grant development process is informed by the expressed needs of the targeted beneficiaries and other relevant stakeholders. The consultations were structured through in-depth interviews using interview guides translated into Kinyarwanda even during the ongoing COVID-19 pandemic (see Annex 1 for more details on the methodology and findings). The interviews were completed in June 2020 and demonstrated that despite the strengths of the CHW program, the CHW cooperatives face several interrelated issues. Specifically, the Public Disclosure Copy consultations and subsequent analysis identified three recurring challenges faced by female-led cooperatives members and leaders: (1) inadequate capacities and knowledge gaps (financial, managerial and operational); (2) limited income generating opportunities; and (3) policy and programmatic gaps. In addition, gender- specific barriers including lack of access to information, high domestic burdens that impede participation, and social norms around decision making that prevent them from assuming leadership roles in the cooperatives.. The feedback from the bottom-up consultations is consistent with findings from a 2016 assessment of CHW cooperatives which found a lack of required technical, financial and managerial skills to run IGAs and become profitable (at the time only 33 percent of the cooperatives were profitable). Although some government institutions, namely the Rwanda Cooperative Agency (RCA), are mandated to develop policies to guide capacity building and training of CHW cooperative members and leaders, these activities are not carried .out regularly, and there is no standardized training curriculum. Through the JSDF seed funding grant, the World Bank, in accordance with JSDF guidelines, held a design, M&E and wrap-up workshop with the key stakeholders from government (Ministry of Health, Rwanda Biomedical Center, Rwanda Cooperative Agency) virtually to finalize the project design, M&E and implementation arrangements of the proposed JSDF grant. Rationale for the JSDF Based on the above constraints identified through seed fund consultation activities, the proposed project seeks to pilot a set of innovative approaches to positively influence cooperative performance and specifically target female-led cooperatives. The targeting of female-led cooperatives was largely informed by the bottom-up consultations which highlighted the barriers they face. Specifically, the technical skills gaps that emerged from the interviews with female CHW cooperative members include: (1) limited skills at leadership level to coordinate, manage and direct the cooperatives forward; and (2) limited skills at the level of CHW members to operate routine activities of the cooperatives, such as conducting productive IGA activities. In addition, female cooperatives members consistently highlighted limited access to financial capital and other resources as a barrier to growth—and that they tend to self-finance their growth by re- investing the capital from PBF payments. As such, beneficiaries of this project will include female managers of cooperatives, members of CHW cooperatives and districts officials. The proposed project builds on and Jun 20, 2022 Page 6 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project complement the existing nutrition and agriculture projects (SPRP and SAIP) insofar as it will reach and support groups that have traditionally been left out or unable to access critical financing and training through the implementation of a comprehensive training package and seed fund grants aimed at increasing knowledge and capacities critical to manage cooperatives and financing to implement new income generating activities. Relationship to CPF The proposed project is aligned with the World Bank’s current Country Partnership Framework (CPF) FY2021-FY2026. The CPF has a major focus on human capital development, including protecting the well- being of the population. The project is also fully aligned with the Government’s health sector strategies, including the Health Sector Strategic Plan 4 (HSSP4 2018-2024); and is aligned with the World Bank Gender Strategy and contributes to the first pillar - “improving gaps in human endowments” - through the promotion Public Disclosure Copy of behavior seeking appropriate health and nutrition services, in combination with new knowledge and enhanced skills on maternal, child and adolescent nutrition. The project is also aligned with the Sustainable Agricultural Intensification and Food Security Project (SAIP), funded by the Global Agriculture and Food Security Program (GAFSP) and supervised by the Bank which aims to increase agricultural productivity, market access, and food security. The SAIP and SPRP projects have already investing in creating and piloting training materials and tools for building the capacity of CHW cooperatives and developing new income generating activities which will be leveraged under the existing JSDF grant. C. Project Development Objective(s) Proposed Development Objective(s) The proposed Project Development Objective (PDO) is to increase the performance (financial and operational) of approximately 40 female-led community health workers (CHW) cooperatives and 4,000 cooperative members participating in grant activities. The outcomes of the project will be improved operational and managerial capacities, implementation of new IGA business plans and increased profitability of the IGAs leading to strengthened and better performing cooperatives. The PDO will be achieved by supporting female-led CHW cooperative members and leaders training and capacity building activities and develop and implement practical, innovative and sustainable IGA models through modest seed grants. The goal being to: (i) promote livelihoods, crop diversification, small livestock and sustainable production, processing and/or commercialization; (ii) identify IGAs with health and nutrition benefits such as community pharmacies, community ambulances, and health commodities like medicines, contraceptives, and feminine hygiene products; and (iii) supporting IGAs for which there is a clear demand. Key Results With JSDF financing, the project will implement a series of activities aimed at building capacity of cooperative members and female leaders with a view to enhance the identification and financing of new IGAs, and ultimately improve the performance (financial and operational) and sustainability of CHW cooperatives. Jun 20, 2022 Page 7 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project Specifically, through capacity building measures and support for the design and implementation of new IGAs, it will help cooperatives to access new livelihood opportunities and generate revenues that can be re- invested in cooperative activities, and in doing so increase the benefits to the communities they serve. The proposed project will be monitored and evaluated to facilitate continuous learning and improve performance. The Single Project Implementation Unit/Rwanda Biomedical Center (RBC) will prepare annual reports which will include information on project activities, key indicators, and beneficiaries. To track performance of project interventions, the following indicators have been identified: Outcome indicators 1. Number of CHW cooperative members and leaders (in female-led cooperatives) demonstrating improved knowledge (financial, operational and managerial) as a result of trainings as measured using pre- and post-training surveys and interviews (Baseline=0, Target=2,000). Public Disclosure Copy 2. Number of CHW cooperatives implementing new IGAs that report an increase in incomes (at least 30%). (livelihood indicator) (Baseline=0, Target=2,000). 3. Number of IGAs proposals developed and implemented by female-led cooperatives (disaggregated by type of IGA) (Baseline=0, Target=300). Intermediate indicators 1. Number of CHW cooperative members, managers and district officials who have received training (disaggregated by gender) (Baseline=0, Target=4,000). 2. Number of CHW cooperative members reporting satisfaction with cooperative management and performance (disaggregated by gender) (Baseline=0, Target=3,000). 3. Number of IGA business plans submitted for small grants funding by female-led cooperatives (Baseline=0, Target=150). 4. Number of exchange visits conducted by CHW cooperative members (Baseline=0, Target=20). Number of case studies developed on project outcomes (Baseline=0, Target=20). D. Preliminary Description Activities/Components The proposed project offers a unique opportunity to improve the operations, management and financial sustainability of the CHW cooperative model in Rwanda, with a focus on cooperatives run by women, as well as contribute to the overall performance of the country’s flagship CHW program. To this end, three main activities are proposed that are aligned with the findings from the consultations carried out in 2020. First, the project will strengthen the technical, managerial and operational capacities of female-led CHW cooperative members and managers, including improved training on new IGAs and technologies, with a view to improve performance and bolster profitability. Second, a special focus would be given to improving Jun 20, 2022 Page 8 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project cooperatives’ access to financing and start-up capital through the provision of small grants. Finally, the project will finance activities related to national and district-level project coordination and management, monitoring and evaluation (M&E) and process evaluations. Considering that women represent over half of the CHW force but only one-fifth of leadership positions within the CHW cooperatives, women-led cooperatives would be targeted and prioritized for assistance in the 13 Stunting Prevention and Reduction Project (SPRP) priority districts. The project complements support for CHWs under the ongoing Bank- funded Stunting Prevention and Reduction Project (SPRP, P164845). The SPRP provides support uniquely for: (i) training CHWs to perform their outreach and awareness activities in the health sector, including developing a competency-based curriculum; and (ii) incentivizing CHWs through the community performance-based financing scheme which aims to motivate these frontline workers to deliver key services while contributing to their incomes and indirectly to their cooperatives. Support for CHW cooperative is beyond the scope of the SPRP which focuses Public Disclosure Copy primarily on nutrition related interventions aimed at reducing childhood stunting. While the GAFSP-funded SAIP supports large established cooperatives, it does not target CHW-led cooperatives. As such, the proposed JSDF grant complements what the SPRP and SAIP are doing by piloting innovative interventions (e.g. new IGASs, comprehensive trainings) where the World Bank and other development partners haven’t reached and addresses specific capacity gaps, especially among female-led cooperatives, thereby allowing CHWs delivering key health and nutrition services to not only continue with that important work but also opens new opportunities for their own financial well-being and that of the community they serve through the implementation of new IGAs. The main activities are as follows: Component 1. Strengthen capacities of CHW cooperatives and improve IGAs (US$1,159,000). This component will strengthen the technical, managerial and operational capacities of female-led CHW cooperatives, managers and district officials, and will support the development, validation, and adoption of context-specific IGAs. Specifically, it will finance the development and implementation and delivery of tailor- made trainings to strengthen technical and institutional capacities and to identify and deliver IGAs. It will be carried out in collaboration with key stakeholders such as the Rwanda Cooperative Agency (RCA) and district authorities which have a stake in the success of these enterprises. For sustainability and institutional strengthening, the RCA is uniquely placed to update and improve existing training modules, addressing key gaps and better adapting them to female-led cooperatives. Sub-component 1.1 Develop training materials for CHW cooperative members, managers, and district officials As a first step, materials that will help cooperative members gain a deeper understanding of a variety of topics such as accessing capital and loans, financial management, and market access will be developed. With these updated materials and training modules, a Training of Trainers approach will be implemented in the 13 SPRP project areas, whereby master trainers from district level will be trained on the new content and then cascade the training to CHW managers. The managers will then train CHWs using a hands-on, interactive Jun 20, 2022 Page 9 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project approach. The RCA is mandated to develop policies that guide the operations of the cooperatives, including the CHW cooperatives. The actual implementation of the training activities will be undertaken by the Ministry of Health’s unit in charge of cooperatives through outsourced expertise (NGO, private company or individual consultants), working in close collaboration with the RCA. Sub-component 1.2 Trainings of master trainers, CHW managers, CHW cooperative members and district officials Trainings and capacity building activities will also be prepared in coordination with the team working on the SAIP to reap synergies and build on existing materials, as well as with the SPRP which is delivering health and nutrition trainings and supporting PBF payments to CHWs. The SAIP project has developed capacity building tools including training manuals in cooperative management, agriculture, and ICT tools that will be used under this grant to build the capacities of CHW cooperatives; support them to develop new income Public Disclosure Copy generating activities; and pilot an approach to match good performing/well-established cooperatives with under-performing/new cooperatives to learn about IGA. The project will also tap the experience of the SAIP with the Rural Invest Tool which supports cooperatives to develop good business plans/IGAs. It is envisioned that there will be four training modules designed for CHW members and managers to fill the current skills gaps: 1. Business skills and financial management 2. Coordinating and managing the cooperatives 3. Designing and implementing new IGAs 4. ICT tools and their use The design of new IGAs and/or strengthening existing ones will enable female-led cooperatives to identify viable investment opportunities, strengthen and/or diversify their activities, and encourage innovation to improve their overall performance. Specifically, the module on developing practical, innovative and sustainable IGA models will support CHWs in female-led cooperatives to develop business plans for pilot or demonstration projects for different products to be financed under Component 2. The goal is to: (i) promote livelihoods, crop diversification, small livestock and sustainable production, processing and/or commercialization; (ii) identify IGAs with health and nutrition benefits such as community pharmacies, community ambulances, and health commodities like medicines, contraceptives, and feminine hygiene products; and (iii) supporting IGAs for which there is a clear demand. Given that the majority of IGAs are related to agriculture, the support provided to these cooperatives will be done in coordination with stakeholders involved in the implementation of the World Bank-funded Agriculture Project, thereby ensuring synergies in investments, and possibly developing twinning arrangements with more experienced cooperatives. Activities that may be co-implemented include trainings, exposure visits (learning tours), and mentoring on nutrition-sensitive agriculture practices. In addition, consultations with local government agencies and local communities will be done to ensure that cooperatives think through appropriate and contextually relevant IGAs. Achieving a higher level of performance and profitability will contribute to the CHW cooperatives’ financial viability and this will allow Jun 20, 2022 Page 10 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project CHWs to dedicate more time delivering health and nutrition services. For example, agricultural IGAs have the potential to contribute to food security and nutrition by helping farmers, fishers, pastoralists and other producers access inputs and markets, and overcome challenges related to poor understanding of food prices in both national and international markets, lack of access to high-quality inputs, lack of access to loans to buy inputs, and lack of transport and other infrastructure bottlenecks in rural areas. The cooperatives can help farmers overcome these barriers by purchasing inputs and marketing products as a group and by facilitating collective access to credit and market outlets, but they need additional support to improve incomes and ensure that food security and nutrition benefits are indeed achieved. Additional details on the targeting criteria for these activities is included below. The overall intention of providing support to CHWs with IGAs is two-fold: 1) Improve the financial and operational sustainability of cooperatives; and 2) Implement new IGAs that have a health/nutrition focus such as selling hygiene product or nutrition supplement. On the latter, the intention is to create a strongly Public Disclosure Copy link between their role as CHWs and their participation in cooperatives; as well as to improve the socio- economic circumstances and satisfaction levels of this workforce thereby allowing them to spend more time on health delivery. During the bottom-up consultations, both beneficiaries and CHWs highlighted the need to better link the demand for CHWs cooperatives IGAs to the local context as this would greatly improve the financial sustainability of the cooperatives and better meet their community needs. This was demonstrated in some health centers where CHWs cooperative choose to deal in certain IGAs, such as selling alcoholic beverages and soft drinks which according to some communities, are non-essential and that dealing in essential commodities (such as food commodities or milk) could generate more revenues for cooperatives as well as align well with the community needs. Considering that the GoR is planning to give smartphones to all CHWs, this represents an opportunity to support CHWs with trainings on the use of these technologies. Using new and existing tools can help them understand market data and report key results thereby improving their capacity and enhancing productivity. Parallel to the CHW trainings, the institutional and technical capacity of national and district government officials to supervise, coordinate and provide oversight of the activities will be built through trainings on the operations, financial management and income-generating opportunities of CHWs so as to improve their capacities to support CHWs in their day-to-day work. Trainings will be adapted to local needs and will be followed by supportive supervision and mentoring to ensure a continuum of capacity development. This component will fund all activities/costs related to delivering trainings (materials, training venues, travel and accommodation for participants, etc.) and technical assistance to the RCA to deliver the trainings. The expected outputs are increased knowledge of participating CHW cooperative members and female leaders, which will be assessed using pre- and post-training interviews and further testing will be conducted. Component 2. Improve access to financing for female-led CHW cooperatives – Sub-Grants (US$1,125,000). Recognizing the constraints and challenges encountered by female-led CHW cooperatives to access financing and start-up capital, the objective of this component is to provide a modest amount of financing via seed Jun 20, 2022 Page 11 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project grants for cooperatives to implement IGAs and improve their access to technologies, complementing the technical assistance and trainings supported under Component 1. A sub-project will be created, and sub-grants will be awarded to the RCA for the distribution of seed funding of up to US$7,500 for female-led cooperatives that participated in the training activities and develop and submit business plans (Component 1). The principal purpose of the sub grants is to fund the activities in the form of demonstration IGAs (e.g., small livestock production, hygiene sales production and sale of agricultural products) and improve their ability to purchase inputs (e.g., technologies, tools, etc.), as well as improve their productivity, all of which will be assessed periodically during implementation. The sub grants will be complemented by the performance-based payments currently being delivered under the SPRP and will remain small/modest throughout the course of implementation. The amount of financing going to cooperatives will vary depending on the proposals submitted but will not Public Disclosure Copy exceed US$7,500. This is a nominal amount that was determined through consultations with CHW cooperative members and leaders and their experience in implementing projects and is the average start-up costs for current IGAs. Building on the technical assistance to develop comprehensive IGA business plans, the cooperatives will use the seed funding to purchase small inputs and goods and apply their training to managing funds and reporting on implementation of their plans. Each cooperative will be able to submit multiple IGA business plan proposals each year, so the total amount of cooperatives supported is estimated at 150. A sub-grant manual will be prepared to underpin the governance of the seed grant activities. Sub grants will be awarded to CHW cooperatives based on the following criteria:  CHW cooperatives must have at least 2 years operational and have demonstrated managerial, operational and administrative capacities to successfully undertake the proposed project/pilot.  CHW cooperatives must have a demonstrated governance structure.  The proposed business plan must include results from market assessment(s) for the proposed IGA to ensure that it fills existing gaps for goods and services in the market and responds to community demand.  The proposed business plan must be technically feasible and linked to technical capacities of its members or include a plan to acquire technical skills rapidly.  The plans must include ideas to leverage additional partnerships and financing.  The plans must include anticipated next steps (sustainability plans) for once seed funding ends. The seed funding to cooperative complements funding received through the SPRP in the form of PBF incentives; in addition, the cooperatives members will be expected to provide in-kind and/or cash contributions to support the start-up and implementation of the seed grants (up to 10% of total). In addition, cooperation and creation of synergies with other organizations involved in health, nutrition and community development can maximize the impact of this grant at the community level. Thus partnerships with local NGOs and donors will be encouraged. Some of the IGAs may include production of small livestock, production of school uniforms, and production of milk or other nutrition commodities. Jun 20, 2022 Page 12 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project A good illustrative example of similar sub grants provided under MAP (Multisectoral AIDS Project)/WB funded project in Rwanda had a funding ceiling of USD $15,000 per cooperative per IGA activity. Previous and ongoing capacity building efforts with CHW cooperatives include those being implemented by the SPRP and the COVID-19 emergency response projects to build their capacities to strengthen community health service delivery and the SAIP to strengthen cooperative capacities. To support learning-by-doing, a systematic process of exposure visits to other districts will be put in place for cooperative members and local/district government officials, and case studies will be developed periodically to document good practices and results achieved. Activities to be financed under this component include financing for the seed grants and operating costs for conducting exchange visits and the expected outputs will be the implementation of new and innovative IGAs, and improved knowledge of CHW cooperative members regarding IGAs. Public Disclosure Copy Component 3: Project Management, Monitoring and Evaluation and Knowledge Dissemination (US$471,800) The aim of this component is to ensure effective management and coordination of the project. The project will utilize the SPRP Single Project Implementation Unit (SPIU), housed in the Rwanda Biomedical Center (RBC), to manage, monitor and coordinate projects activities, and handle fiduciary aspects (financial management and procurement), safeguards compliance monitoring, M&E, and produce annual progress reports on the project; and will provide resources for additional staffing, equipment, and capacity to carry out monitoring, evaluation, and dissemination activities. Sub-Component 3.1 Project Management and Administration (PMA). The RBC/SPIU will be responsible for the day-to-day implementation of the project activities and will need to procure a small amount of equipment, and consultant services to coordinate and oversee the activities. As such, the grant will fund the positions of a staff and consultants for planning, budgeting, monitoring and evaluation, training, and monitoring and supervision. Sub-Component 3.2 Monitoring and Evaluation (M&E): The proposed project will be monitored and evaluated to facilitate continuous learning and improvement. This subcomponent includes the hiring of an M&E consultant and impact evaluation specialist for the final impact evaluation. Moreover, the RBC/SPIU (implementing agency) has a strong M&E system in place built during several past projects undertaken for the World Bank. Performance indicators will be selected to capture the overall objectives of the project. Annual reporting is expected, and district health authorities will consolidate technical and financial reports from target districts and other stakeholders on a quarterly basis. Progress reports will include information on project activities, key indicators, and beneficiaries. This sub-component will build the required M&E systems, strategies, and staffing. Sub-Component 3.3: Knowledge Dissemination. The impact of the project will be rigorously evaluated, the results of which will be shared with stakeholders as part of planned workshops to share lessons learned and project gains. The project will provide the necessary analytic and technical assistance support to the RBA and Jun 20, 2022 Page 13 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project RBC to build a knowledge base and make future decisions on longer term institutional, financing, and policy reforms required to achieve and sustain results over time. Environmental and Social Standards Relevance E. Relevant Standards ESS Standards Relevance Assessment and Management of Environmental and Social ESS 1 Relevant Risks and Impacts ESS 10 Stakeholder Engagement and Information Disclosure Relevant Public Disclosure Copy ESS 2 Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and ESS 3 Relevant Management ESS 4 Community Health and Safety Not Currently Relevant Land Acquisition, Restrictions on Land Use and Involuntary ESS 5 Not Currently Relevant Resettlement Biodiversity Conservation and Sustainable Management of ESS 6 Not Currently Relevant Living Natural Resources Indigenous Peoples/Sub-Saharan African Historically ESS 7 Not Currently Relevant Underserved Traditional Local Communities ESS 8 Cultural Heritage Not Currently Relevant ESS 9 Financial Intermediaries Not Currently Relevant Legal Operational Policies Safeguard Policies Triggered Explanation (Optional) Projects on International Waterways OP Project activities are not going to interfere with No 7.50 international waterways. Project activities will not be conducted in disputed Projects in Disputed Areas OP 7.60 No areas. Summary of Screening of Environmental and Social Risks and Impacts The project will not finance any construction works and hence will not lead to alteration of natural habitats. It will not lead to generation of any significant amount of pollutants. It will only finance goods for small scale income generating activities (IGAs). The IGAs to be financed by the small seed grants of $1,500-$2,000 include kitchen gardens, small livestock production, hygiene products sales and sale of agricultural products. The small seed grants will not cause any significant environment, health, and safety (ESHS) risks. Though very small in scale, potential environment, health and safety risks associated with the IGAs include waste feed, animal waste, odors (e.g. animal housing & waste management), bioaerosols, animal diseases, exposure to physical hazards, overgrazing may contribute to soil losses, chemicals that may be applied to control pests, Jun 20, 2022 Page 14 of 15 The World Bank Rwanda JSDF - Support to Community Health Workers Project parasites and vectors, crop residue waste management, fertilizers. The anticipated risks could be readily addressed if appropriate environment, health, and safety (EHS) considerations are properly covered in each of the Business Plans to be prepared under Component I. To this end, an environmental and social management plan (ESMP) or a guideline on EHS risk management will be annexed to each Business Plans depending on the nature of the activities to be financed. This will also be reflected in the Environmental and Social Commitment Plan. CONTACT POINT World Bank Contact : Naoko Ohno Title : Senior Operations Officer Public Disclosure Copy Telephone No : 5220+39103 / Email : Borrower/Client/Recipient Borrower : Ministry of Finance (MINECOFIN) Contact : Gerard Mugabe Mugabe Title : Division Manager External Finance Division Telephone No : 250788591189 Email : gerald.mugabe@minecofin.gov.rw Implementing Agencies Implementing Rwanda Biomedical Center Agency : Contact : Dr. Sabin Nsanzimana Title : Director General Telephone No : 250725792842 Email : sabin.nsanzimana@rbc.gov.rw FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Jun 20, 2022 Page 15 of 15