FOR OFFICIAL USE ONLY Report No: PAD3109 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 9.4 MILLION (US$13 MILLION EQUIVALENT) TO THE REPUBLIC OF THE MARSHALL ISLANDS FOR A MULTISECTORAL EARLY CHILDHOOD DEVELOPMENT PROJECT February 6, 2019 Health, Nutrition & Population Global Practice East Asia And Pacific Region This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information. CURRENCY EQUIVALENTS (Exchange Rate Effective December 31, 2018) Currency Unit = United States Dollar (US$) SDR 1 = US$1.39079 US$1 = SDR 0.719 FISCAL YEAR October 1 – September 30 Regional Vice President: Victoria Kwakwa Country Director: Michel Kerf Senior Global Practice Director: Timothy Grant Evans Practice Manager: Enis Barış Task Team Leader(s): Aparnaa Somanathan, Binh Thanh Vu ABBREVIATIONS AND ACRONYMS ADB Asian Development Bank ANC Ante-natal care BOMI Bank of Marshall Islands CC Cabinet Committee on ECD CCT Conditional Cash Transfers CFA Compact of Free Association CIU Central Implementing Unit CSGs Compact Sector Grants DA Designated Account ECD Early Childhood Development EPPSO Economic Policy Planning and Statistics Office ESMF Environmental and Social Management Framework FM Financial Management FMIS Financial Management Information System GRM Grievance redress mechanism GRS Grievance redress service HESA Health, Education and Social Affairs HIES Household Income and Expenditure Survey ICHNS RMI Integrated Child Health and Nutrition Survey IMF International Monetary Fund IMRs Infant mortality rates LFPR Labor Force Participation Rate MALGOV Majuro Atoll Local Government MCH Maternal and child health MEAL Monitoring, Evaluation and Learning M&E Monitoring and Evaluation MIS Management Information System MISSA Marshall Islands Social Security Administration MMR Maternal Mortality Rate MOCIA Ministry of Culture and Internal Affairs MOEST Ministry of Education, Sports and Training MOF Ministry of Finance MOHHS Ministry of Health and Human Services MOUs Memoranda of Understanding NGO Non-governmental organization OCS Office of the Chief Secretary OIs The Outer Islands PDO Project Development Objectives PICs Pacific Island Countries PIU Project Implementation Unit POM Project Operations Manual PPA Project Preparation Advance PPSD Project Procurement Strategy for Development PSC Program Steering Committee PSS Public School System RMI The Republic of the Marshall Islands RMNCH-N Reproductive, maternal, newborn and child health and nutrition RPF Regional Partnership Framework SBCC Social and Behavior Change Communication STEP Systematic Tracking of Exchanges in Procurement TA Technical Assistance TORs Terms of Reference WB The World Bank WUTMI Women United Together Marshall Islands The World Bank Multisectoral Early Childhood Development Project (P166800) TABLE OF CONTENTS DATASHEET ........................................................................................................................... 2 I. STRATEGIC CONTEXT ...................................................................................................... 8 A. Country Context................................................................................................................................ 8 B. Sectoral and Institutional Context .................................................................................................... 8 C. Relevance to Higher Level Objectives............................................................................................. 15 II. PROJECT DESCRIPTION.................................................................................................. 15 A. Project Development Objective (PDO) ........................................................................................... 15 B. Project Components ....................................................................................................................... 18 C. Project Beneficiaries ....................................................................................................................... 23 D. Results Chain .................................................................................................................................. 24 E. Rationale for Bank Involvement and Role of Partners ................................................................... 26 F. Lessons Learned and Reflected in the Project Design .................................................................... 26 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 27 A. Institutional and Implementation Arrangements .......................................................................... 27 B. Results Monitoring and Evaluation Arrangements......................................................................... 28 C. Sustainability................................................................................................................................... 29 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 29 A. Technical, Economic and Financial Analysis ................................................................................... 29 B. Fiduciary.......................................................................................................................................... 32 C. Safeguards ...................................................................................................................................... 33 V. KEY RISKS ..................................................................................................................... 34 VI. RESULTS FRAMEWORK AND MONITORING ................................................................... 36 ANNEX 1: Implementation Arrangements and Support Plan .......................................... 43 ANNEX 2: Project Description ........................................................................................ 56 ANNEX 3: Technical, Economic and Financial Analysis.................................................... 68 ANNEX 4: Map of the Republic of the Marshall Islands .................................................. 74 The World Bank Multisectoral Early Childhood Development Project (P166800) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Marshall Islands Multisectoral Early Childhood Development Project Project ID Financing Instrument Environmental Assessment Category Investment Project P166800 B-Partial Assessment Financing Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [ ] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Disbursement-linked Indicators (DLIs) [✓] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made Disaster [ ] Alternate Procurement Arrangements (APA) Expected Approval Date Expected Closing Date 28-Feb-2019 31-Dec-2024 Bank/IFC Collaboration No Proposed Development Objective(s) To improve coverage of multisectoral early childhood development services The World Bank Multisectoral Early Childhood Development Project (P166800) Components Component Name Cost (US$, millions) Component 1. Improve coverage of essential RMNCH-N services 3.66 Component 2. Improve coverage of stimulation and early learning activities 3.16 Component 3. Social assistance for early years families 2.91 Component 4. Strengthening the multisectoral ECD system and Project management 3.27 Organizations Borrower: The Republic of the Marshall Islands Implementing Agency: Ministry of Finance Ministry of Culture and Internal Affairs Ministry of Health and Human Services Ministry of Education, Sports and Training Office of Chief Secretary PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 14.92 Total Financing 14.92 of which IBRD/IDA 13.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 13.00 IDA Grant 13.00 Non-World Bank Group Financing Counterpart Funding 1.92 Borrower/Recipient 1.92 Page 3 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount National PBA 0.00 13.00 0.00 13.00 Total 0.00 13.00 0.00 13.00 Expected Disbursements (in US$, Millions) WB Fiscal Year 2019 2020 2021 2022 2023 2024 2025 Annual 0.93 2.00 2.50 2.50 2.50 1.58 1.00 Cumulative 0.93 2.93 5.43 7.93 10.43 12.00 13.00 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Education, Social Protection & Labor Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of Yes country gaps identified through SCD and CPF b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or Yes men's empowerment c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Moderate 2. Macroeconomic  Moderate 3. Sector Strategies and Policies  Substantial Page 4 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 4. Technical Design of Project or Program  Substantial 5. Institutional Capacity for Implementation and Sustainability  Substantial 6. Fiduciary  Substantial 7. Environment and Social  Moderate 8. Stakeholders  Moderate 9. Other 10. Overall  Substantial COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✔ Performance Standards for Private Sector Activities OP/BP 4.03 ✔ Natural Habitats OP/BP 4.04 ✔ Forests OP/BP 4.36 ✔ Pest Management OP 4.09 ✔ Physical Cultural Resources OP/BP 4.11 ✔ Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔ Safety of Dams OP/BP 4.37 ✔ Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Legal Covenants Page 5 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Sections and Description Section I.A.1 of Schedule 2 to the Financing Agreement: The Recipient shall maintain the Early Childhood Development Cabinet Committee until the closing date, and shall provide high level strategic leadership and guidance for the Project through the Early Childhood Development Cabinet Committee in accordance with the provisions of the Financing Agreement and the Project Operations Manual. Sections and Description Section I.A.3 of Schedule 2 to the Financing Agreement: The Recipient shall maintain until the closing date the Program Steering Committee. Sections and Description Section I.A.5 of Schedule 2 to the Financing Agreement: To this end, the Recipient shall, by no later than three months after the Effective Date, establish and thereafter maintain until the closing date, the Early Childhood Development Working Group. Sections and Description Section I.A.6 of Schedule 2 to the Financing Agreement: The Recipient shall establish, by no later than three months after the Effective Date, and thereafter maintain until the closing date, the Project Implementation Unit within the Office of the Chief Secretary. Sections and Description Section I.B.1 of Schedule 2 to the Financing Agreement: The Recipient shall prepare and adopt, by no later than three (3) months after the Effective Date, the Project Operations Manual. Sections and Description Section I.B.2 of Schedule 2 to the Financing Agreement: The Recipient shall ensure that the Project is implemented in accordance with the provisions of the Project Operations Manual. Sections and Description Section I.D of Schedule 2 of Schedule 2 to the Financing Agreement: To facilitate the carrying out of Part 3 of the Project, the Recipient shall sign a Memorandum of Understanding, in form and substance acceptable to the Association, between the Ministry of Culture and Internal Affairs, the Ministry of Education, Sports and Training, the Ministry of Health and Human Services, the Majuro Atoll Local Government, and Marshall Islands Social Security Administration detailing the division of responsibilities and cooperative arrangements for implementing Part 3 of the Project. Sections and Description Section I.E of Schedule 2 to the Financing Agreement: The Recipient shall ensure that the Project is carried out with due regard to appropriate health, safety, social, and Page 6 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) environmental practices and standards, and in accordance with the Safeguards Instruments. Sections and Description Section I.F of Schedule 2 to the Financing Agreement: The Recipient shall prepare and furnish to the Association not later than: (a) four (4) months after the Effective Date (or such later date as the Association may agree); and (b) August 31 of each year for every subsequent year during the implementation of the Project (or such later date as the Association may agree); for the Association’s no-objection, an Annual Work Plan and Budget. Sections and Description Section II.1 of Schedule 2 to the Financing Agreement: The Recipient shall furnish to the Association each Project Report not later than forty-five (45) days after the end of each calendar semester, covering the calendar semester. Sections and Description Section II.2. of Schedule 2 to the Financing Agreement: The Recipient shall, not later than December, 2022 (or such other date as the Association may agree in writing), prepare and furnish to the Association a mid-term report. Conditions Type Description Disbursement Section III.B.1.(b) of Schedule 2 to the Financing Agreement: No withdrawal shall be made under Category (2) unless and until the Association has received evidence to its satisfaction that: (i) the following aspects of the Conditional Cash Transfer Program have been developed: (A) a management information system for the enrolment, compliance verification and payments; (B) a grievance redress mechanism; and (C) guidelines for a monitoring and evaluation framework, all as satisfactory to the Association; (ii) the Memorandum of Understanding has been finalized and signed in accordance with Section I.D of Schedule 2 to the Financing Agreement; and (iii) the Project Operations Manual has been prepared and adopted in accordance with Section I.B of Schedule 2 to the Financing Agreement. Page 7 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) I. STRATEGIC CONTEXT A. Country Context 1. The Republic of the Marshall Islands (RMI) is one of the world’s smallest, most isolated, and vulnerable nations. The country consists of 29 atolls and five isolated islands (24 of which are inhabited) and has a total land mass of just 181 km² set in an area of over 1.9 million km2 in the Pacific Ocean. The population of the RMI was estimated at 53,0661 in 2016, of which the two largest urban centers, Majuro (the nation’s capital) and Ebeye, have populations of 28,000 and 9,614, respectively. The RMI was consolidated into the Trust Territory of the Pacific Islands governed by the United States during the Second World War. It became self-governing in 1979 and achieved formal independence in 1986. 2. The RMI faces many of the development challenges common to small, remote economies with dispersed populations. Small size and remoteness increase the costs of economic activity and make it difficult to achieve economies of scale. Remoteness also imposes transport costs that increase the costs of trade and fundamentally constrain competitiveness of exports of goods and services in world markets. These same factors also increase the cost and complexity of providing public services. Moreover, geographical characteristics, including populations centered on small, low-lying atolls, make the country extremely vulnerable to natural disasters. The RMI is one of the most vulnerable countries to climate change and rising sea levels. 3. Economic growth accelerated in 2016 and macroeconomic forecasts predict continuous economic growth over the next five years. Growth rates are expected to revolve around 2.5 percent over the near term and remain positive (but lower) over the medium term2. The fishing sector remains the main source of revenue, representing 18 percent of GDP in 2017. Infrastructure development, public administration and education were the main drivers of GDP growth in 2017. 4. The RMI is a sovereign nation in a “Compact of Free Association” (CFA) agreement with the United States. The first CFA was signed in 1983 and continued through 2003. An amended CFA became effective on May 1, 2004, providing approximately US$37 million in grants per year through the Compact Sector Grants (CSGs). After 2023, the CSGs will cease, although the CFA remains in force in perpetuity. While a Compact Trust Fund was established to replace CSGs from 2024 onward, based on current projections, contributions to the Compact Trust Fund are inadequate to assure a smooth transition, and annual Compact Trust Fund income can be expected to fall short of what is needed to replace the CSGs in 2024, which presents a key challenge to the country’s fiscal sustainability. With substantial constraints to export-led growth, the Marshall Islands is heavily dependent on aid and other fiscal transfers. The current account deficit is largely financed by grant inflows. Aid and fiscal transfers, primarily from the US, support reasonable though declining standards of living for most of the population. B. Sectoral and Institutional Context 5. The foundations of human capital formation are at risk in the RMI due to poor health and nutrition during pregnancy and early life, lack of early stimulation and learning, and exposure to poverty and severe stress during the early years of life (Table 1). Maternal mortality rate (MMR) and infant mortality rates (IMR) are much higher than for other Pacific Island comparator countries and relative to the RMI’s income level. Child stunting, or low height-for-age and an indicator of chronic malnutrition, affects over one-third (35 percent) of children under age 5. Of most recently born children age 0-59 months, 12 percent were estimated to have low birthweight (<2,500 g) at birth. Although robust measures are not available, data from the Integrated Child Health and Nutrition Survey (ICHNS) point to deficits in overall 1 RMI Government Statistics Office projections based on the 2011 RMI Census 2 IMF, 2017 Page 8 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) child developmental outcomes3. Physical health and growth, literacy and numeracy skills, socio-emotional development, and readiness to learn are vital domains of a child’s overall development. According to the ICHNS, 79 percent of children are developmentally on track (see Table 2 for definition) in 3 of 4 domains, ranging from 86 percent of children age 48- 59 months compared to 71 percent of children age 36-47 months. Overall, children in the wealthiest families show better health, education and nutrition outcomes compared with children in the poorest families. Table 1: Health, nutrition, and child development outcomes Maternal and Child Health Outcomes Infant mortality rate (deaths per 1,000 live births) +(deaths per 1,000 live births) + 28 Under-5 mortality rate (deaths per 1,000 live births) + 34 Maternal mortality ratio (deaths per 100,000 live births) + 92 Low birth weight (<2,500 g), (% last born children 0-59 months*) 11.6 Maternal and Child Nutritional Outcomes Underweight (% children 0-59 months*) 11.7 Stunting (% children 0-59 months*) 35.3 Wasting (% children 0-59 months*) 3.6 Overweight (% children 0-59 months*) 3.8 Underweight/Thinness (BMI<18.5 kg/m2), % WRA* 1.8 Overweight (BMI 25.0-29.9 kg/m2), % WRA* 72.7 Obesity (BMI >30 kg/m2), % WRA* 45.1 Child Development Outcomes Percent of children age 36-59 months developmentally on track for indicated domains Literacy – Numeracy 55.4 Physical 92.8 Social-Emotional 72.4 Learning 87.6 ECDI Index Score* 78.9 Literacy-numeracy: Developmentally on track if at least two of the following are true: Can identify/name at least ten letters of the alphabet, Can read at least four simple, popular words, Knows the name and recognizes the symbol of all numbers from 1 to 10. Physical: Developmentally on track if one or both of the following is true: Can pick up a small object with two fingers, like a stick or a rock from the ground, Is not sometimes too sick to play. Social-emotional: Developmentally on track if at least two of the following are true: Gets along well with other children, Does not kick, bite, or hit other children, Does not get distracted easily. Learning: Developmentally on track if one or both of the following is true: Follows simple directions on how to do something correctly, When given something to do, is able to do it independently. Sources: *UNICEF Integrated Child Health and Nutrition Survey, 2017; +MOHHS Key Performance Indicators Report, 2017; ++MOHHS Annual Report, 2017; Notes: WRA: Women of reproductive age (15-49). Note: Data are subject to the usual errors associated with small sample sizes, and in the case of population data such as IMR and MMR issues associated with measurement of mortality in small populations. 6. In the RMI, children experience adversities across multiple domains that undermine children’s opportunities to learn, earn, innovate, and compete. Poor child development in the RMI is underpinned by a range of factors spanning across sectors. They include: (a) inadequate access to effective and quality maternal and child health (MCH) services including immunization coverage; (b) insufficient opportunities for early stimulation and early learning; (c) lack of support through formalized social protection; and (d) limited availability, affordability, and consumption of nutritious diets, 3 The ICHNS calculates the Early Child Development Index (ECDI) based on selected milestones that children are expected to achieve by ages 3 and 4. There are notable limitations to the interpretation of the overall ECDI and the validity of the items included in the index. The literacy-numeracy items are more closely aligned with capabilities expected of children at the upper end of the age range, and physical items more closely aligned with developmental milestones for children at the lower end of the age range. Thus, it is unsurprising to see higher performance in the physical domain and lower performance in literacy-numeracy. Page 9 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) especially for children from vulnerable families.4 Cutting across all of this is a general low awareness of the importance of early child stimulation, health and nutrition. Health System Context: Service Delivery and Financing 7. While health outcomes have improved slowly over time, the RMI faces significant challenges addressing the dual burden of disease. Between 1990 and 2016, IMRs declined from 45 to 30 deaths per 1000 live births and life expectancy increased from 65 to 75 years. On both outcomes, the RMI compares poorly against other Pacific Island countries (Figure 1). The incidence of communicable diseases remains high. Hepatitis B is the fourth leading cause of mortality. In 2013, the RMI had the highest mortality rate from tuberculosis in the Pacific at 40/100,000 people5 prompting a mass screening and treatment program led by the World Health Organization in 2017. 8. The RMI has undergone a rapid epidemiological transition with noncommunicable diseases (NCDs) presently the leading cause of morbidity and mortality alongside the unfinished burden of maternal, neonatal, and communicable diseases. Diabetes, cardiovascular disease and cancer were top three causes of mortality in RMI in 20176 with obesity a main risk factor for premature mortality and morbidity. In 2017, 74 percent of deaths for adults aged 15 to 49 years were attributed to NCDs--70 percent for males and 79 percent for females. Unhealthy diet is a main contributor to obesity, which is significantly higher among women (78 percent) compared to men (66 percent)7. 9. Poor maternal health and nutrition is an underlying cause of preventable deaths among women, an impediment to improving women’s health endowments, and a threat to the human capital formation of the next generation in the RMI. Women’s nutrient requirements change with the increasing physiological demands of pregnancy and lactation. The quantity and quality of maternal diet is critical to promote the health and wellbeing of herself and her offspring. However, there is evidence of poor dietary quality among Marshallese women. Among caregivers of children under age 2 years, only 27 percent consumed minimum dietary diversity of at least five food groups in the previous day. Consumption of low nutrient density foods, such as sugar-sweetened beverages (41 percent) and sweet foods (47 percent) is much more common than Vitamin A-rich fruits and vegetables (36 percent) and dark green leafy vegetables (15 percent). Ability to achieve minimum dietary diversity is associated with household wealth, still less than half of caregivers in the wealthiest households consume a minimally diverse diet. 10. Unhealthy diet, overweight/obesity, and other NCDs during pregnancy requires careful management and treatment. In childbearing, women require a continuum of high quality care to ensure the best possible health outcome for them and their new-borns. This includes care at the clinic through early and frequent antenatal and postnatal care contacts, as well as high skilled obstetric care at delivery. Obese pregnant women face increased risk of obstetric complications such as recurrent miscarriage, congenital anomalies in the fetus, gestational hypertension and preeclampsia, gestational diabetes, preterm birth, cesarean delivery, post-partum hemorrhage and infections. These maternal health and nutrition conditions have further impacts on fetal growth and development that can impact the health of the child in later life. Infants born to obese mothers are at increased risk of macrosomia (being born with birth weight >4500g) and childhood obesity. However, pregnancy has also been shown to be an opportunity when women are motivated to improve their own health and nutrition behaviors (such as diet and smoking). Consistent with the fetal 4 While poor diet is a population-wide concern, there are distinct issues related to the diets and nutrient intake of women, infants, and young children that have a profound impact on nutritional status in the first 1,000 days of life. The modern Marshallese diet consists largely of starchy staples (such as rice, wheat flour products, and ramen noodles) and meat (often canned or processed). Food in the RMI is largely imported, with populations on the Outer Islands (OI) relying on traditional diets of fresh fish and fruit. Food availability is not an issue at the population level, but geographic access and affordability remain barriers to widespread improvements in consumption diversity and dietary quality. According to the 2017 ICHNS, 40 percent of households had some level of food insecurity, with 20 percent of households experiencing severe food insecurity. 5 Witten et al. 2017. 6 Ministry of Health and Human Services Annual Report, 2017 7 MOH, MIEPI, PIHOA. 2018. Marshall Islands NCD Hybrid Survey, Preliminary Results. Page 10 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) origins of disease hypothesis, an effective response to the growing burden of NCDs involves addressing poor health and nutrition outcomes in pregnancy and early childhood. Teenage pregnancy and early childbearing are a growing concern in the RMI, where 15 percent of mothers of children under age 5 were under 20 years old at the time of birth.8 11. Coverage of effective and quality health services for childhood conditions such as acute respiratory infection, fever, and diarrhea is low and variable, and an impediment to optimal health and nutrition of women and children. Care from a health provider was sought for only about half of children with diarrhea. Only about one quarter (28 percent) of diarrhea cases were treated with oral rehydration salts or recommended homemade fluids, with eight percent of diarrhea cases receiving oral rehydration salts and zinc. Only 55 percent of children have complete immunization by the age of 5 (Table 2), and there is currently limited monitoring and promotion of child growth and development. 12. Coverage of facility-based reproductive, maternal, newborn, and child health and nutrition (RMNCH-N) services is relatively high in Ebeye and Majuro but challenges remain in ensuring sufficient supply of commodities outside Majuro. Timely receipt of the first antenatal care visit is of paramount importance as it allows for the opportunity to screen for and manage pregnancy-related NCD risks, as well as provide guidance on modifiable lifestyle factors (diet, smoking, physical activity) to improve pregnancy outcomes. However, early ante-natal care (ANC) remains an issue in RMI, with only 34 percent of women receiving their first ANC visit in the first trimester (Table 2). Delivery with a skilled birth attendant can reduce the risk of maternal mortality by 20 percent, yet disparities in access persist for rural women and for the poorest, with only 66 percent of rural women delivering with a skilled provider. Most women receive iron-folic acid supplementation (67 percent) or multiple micronutrient supplementation (49 percent) during pregnancy. However, adequate supplementation is an issue, as only 26 percent of women consume more than 90 iron/folic acid tablets, and iron/folic acid consumption is lowest among mothers less than 20 years old at time of birth (14 percent). Moreover, programs such as vitamin A supplementation (54 percent) and child deworming (32 percent) have lower coverage. Public health programs promoting healthy diet and physical activity are donor driven and sporadic. Access to adolescent friendly reproductive health education and services remains a gap to be filled. 13. Though health system performance has improved, considerable investment is needed to realize the healthy islands vision outlined in the Ministry of Health and Human Services (MOHHS) Strategic Plan (2017-2019) and deliver quality, effective primary health care9 (Table 2). Health services are delivered in two hospitals (one each in Majuro and Ebeye) and fifty-six public health centers, primarily located on the Outer Islands (OIs)10. The MOHHS offers MCH Clinics in Majuro and Ebeye, which see infants at two weeks postpartum and according to the routine immunization schedule. A ‘zone nurse’ program and OIs’ mobile health missions provide outreach services, though limited financing for operational cost, transport, equipment, and availability of adequately trained staff limit the frequency and quantity of outreach services provided. In both facilities and communities, little emphasis is placed on supporting caregivers to improve health and nutrition behaviors. MOHHS reports a number of human resource challenges, including: (i) suboptimal availability and distribution of human resources; (ii) limited communication across programs and providers; and (iii) insufficient staff training, supervision, and performance management. Unreliable availability of essential commodities and equipment (e.g. vaccine cold chain, micronutrient supplements, communication materials) pose barriers to improving coverage of priority primary health care services, especially in the OI11. 8 ICHNS 2017. 9 WHO defines these as: (a) leadership and governance; (b) service delivery; (c) health system financing; (d) health workforce; (e) medical products, vaccines, and technologies; and (f) health information systems. 10 Community health centers are the focus for preventive, promotive, and essential clinical health services and are staffed by full-time Health Assistants (high school graduates, majority male, who are trained to provide basic services but are reported to have insufficient professional competencies). However, there are cultural challenges related to the acceptability of male health assistants providing RMNCH- N services, and for this reason many women on the OIs often: (a) don’t seek preventive/promotive services; (b) see traditional providers; or (c) travel to Ebeye/Majuro and for only the most essential RMNCH-N services. 11 US CDC, ADB Regional TA on Cold Chain, UNICEF Page 11 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Figure 1: Infant mortality rate and life expectancy rate relative to income and other comparators Note: Both X and Y axes are on log scale Source: World Bank, 2017 Table 2: Health Financing, System, and Service Delivery, the Republic of Marshall Islands, 2017 Health Financing Total health spending as a share of GDP (%) 23 Government (including on-budget donor) health spending as a share of GDP (%) 15 Government health spending per capita (US$) 560 Health System Hospital beds per capita (National) 1:357 Majuro (101 beds) Ebeye (54 beds) Human Resources for Health (total) 585 Doctors per capita 1:1,288 Nurses per capita 1:254 Primary health care facilities 58 Hospital 2 Health Center 56 Health Service Coverage Percent of women giving birth with a skilled provider+ 66 Immunization rates (children 19-35 months): Measles Mumps and Rubella 1++ 84 Immunization completeness++ 55 Percent of women receiving at least one ante-natal care visit during the first trimester++ 34 Percent of children with under age 5 with diarrhea in the last 2 weeks for whom advice 47.1 or treatment was sought from a health facility or provider* Percent of children under age 5 with diarrhea who received ORS and zinc* 7.5 Sources: *UNICEF Integrated Child Health and Nutrition Survey, 2017; +MOHHS Key Performance Indicators Report, 2017; ++MOHHS Annual Report, 2017; Notes:; ORS: Oral rehydration solution; Complete immunization: Children age 19-35 months of age complete for 4- Page 12 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) DTaP, 3-Polio, 3-HepB, 1-HIB, 1-MMR. Note: Data are subject to the usual errors associated with small sample sizes, and in the case of population data such as IMR and MMR issues associated with measurement of mortality in small populations. 14. Similar to many Pacific Islands, overall spending on health is high and highly donor dependent. Government health spending (including on-budget donor assistance) in RMI is 15 percent of GDP or US$560 per capita. Government health spending accounts for 65 percent of Total Health Spending (THE), followed by off-budget development assistance (18 percent), out-of-pocket payments (13 percent) and prepaid private spending (3 percent)12. Hospitals are the largest cost drivers in the health sector: general hospital services and specialized hospital services represent 19 and 27 percent of government spending respectively. US Federal Grants and Programs drive spending on key preventive and public health program (e.g. immunization, maternal and child health, and family planning). Education System Context: Service Delivery and Financing 15. The RMI is one of the only Pacific Island Countries (PICs) without a national policy on Early Childhood Care and Education or Early Learning and Development Standards13. The RMI school system serves kindergarten to Grade 12, has 112 schools, and is made up of public and private schools. Pre-school is provided for 3-4-year-olds by private providers only. Government funding to private pre-schools is based on enrollment, performance and accreditation. Since 2004, the national kindergarten program has been integrated into public elementary schools and provided free of charge to children who turn 5 at the start of the school year. 16. Only 5 percent of children aged 36-59 months attend an organized early childhood education program (ICHNS 2017). Enrollments in elementary school have been static for several years at around 83-86 percent, and they drop off again in secondary school to 48-58 percent14. Enrollment rates have increased in urban areas and decreased in the OI probably as a consequence of migration. Low school enrollments, high dropout rates, and low educational outcomes are of great concern to the Public School System (PSS) of the Ministry of Education, Sport and Training (MOEST), and test scores from the national RMI Standards Assessment Test series highlight poor outcomes for those in school. Table 3: Education outcomes, system, and financing, 2017 Education Outcomes Outcome Education Financing and System Primary* enrollment rate (gross, net) 86%, 79% Total education spending as a share of GDP - (%) Persistence** to Grade 8 78% Government (including on-budget donor) 16 education spending as a share of GDP (%) Secondary enrollment rate (gross, net) 48%, 45% Government education spending per capita 572 (US$) Persistence** to Grade 12 45% Student:teacher ratio (elementary) Majuro 17.6:1 Ebeye 19.5:1 OI 10:1 Students attaining proficient or above Elementary schools on MISAT*** Majuro 11 Grade 3 (girls, boys) 35%, 29% Ebeye 3 Grade 6 (girls, boys) 21%, 18% OI 66 Pre-schools Public 0 Private 10 *Primary/Elementary education in RMI is defined as grades K-8 ** The Education Statistics Digest reporting these figures uses the term “completion”; however, based on the explanation of how 12 Institute for Health Metrics and Evaluation, 2018 13 UNICEF, 2017. Status Report on Early Childhood Care and Education in Pacific Island Countries (PICs). 14 Digest of education statistics 2016-2017, MOEST/PSS Page 13 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) these figures are calculated, it is closer to “persistence” according to the UIS definition. *** Marshall Islands Standards Assessment Test Source: Marshall Islands Public Schools System – Digest of Education Statistics 2016-2017 17. Parent/caregiver interaction and the household environment in the RMI do not compensate adequately for the lack of formal or community-based early childhood development (ECD) services. Nationwide, 72 percent of children age 36-59 months were engaged by adults in four or more activities in the previous three days15; children were more likely to have their mothers engaged in these activities (59 percent) than their fathers (2 percent). Adult engagement with children varies most widely by the education level of the child’s caregiver: it is as low as 50 percent among children whose caregivers’ highest level of education is primary school compared to 85 percent among children with caregivers who attended higher education. Children are less likely to have their biological mother engaged in learning when the mother is under age 20 (42 percent) compared to age 35 and over (53 percent). Less than one-fifth (18 percent) of children age 0-59 months live in families with three or more children’s books, with large variations by income. 18. Government expenditures on education are 16 percent of GDP, or US$572 per capita (Table 3). Education was the second largest expenditure item in 2016 with US$24.6 million spent on this sector. Revenues from the Compact Fund represent the main source of financing (more than three quarters of all funds) and are expected to remain stable over time. It is estimated that roughly one fifth of the budget is allocated to pre-primary education, while the coverage and availability of such services is extremely limited. Primary and secondary education represent relatively small shares of the education budget (18 and 13 percent respectively). 19. Challenges in the duration and quality of Marshallese education contribute to gaps in the skills and participation of the Marshallese labor force. The female Labor Force Participation Rate (LFPR) is low at 52.3 percent16 and the share of Marshallese women in paid employment (26 percent) is just over half the rate of Marshallese men (48 percent) (Republic of the Marshall Islands, 2018). Central to the low levels of female LFPR and women’s economic activity are women’s unpaid domestic work and caregiving responsibilities. For young women, the early onset of motherhood and other care responsibilities can influence their aspirations for education and employment. The College of the Marshall Islands’ identified the lack of appropriate childcare was identified as an obstacle to women completing their studies.17 Social protection system 20. The RMI has very limited coverage through formal social protection programs, even when compared to other PICs. Over the past decades, the RMI has introduced a defined benefit pension scheme for formal sector workers, as well as a school feeding program for primary school children in Majuro only. Beyond these two schemes, there are no formal SP programs to support vulnerable groups (the poor, informal sector elderly, disabled etc.). The prevalence of ‘hardship’ in RMI is amongst the highest for PICs18. Across most PICs, 20 to 30 percent of the population lives below the nationally- defined hardship threshold; for RMI, hardship is experienced by 51.1 percent of the population. 21. There is widespread agreement within the Government of RMI that although progress has been made in increasing economic growth and reducing poverty, there is a clear need to invest in the foundations of human capital 15 The maximum number of activities is six, including: (A) Reading books to or looking at picture books with the child, (B) Telling stories to the child, (C) Singing songs to or with the child, including lullabies, (D) Taking the child outside the home, compound, yard, or enclosure, (E) Playing with the child, and (F) Naming, counting, or drawing things to or with the child. 16 Which is low compared to RMI male LFPR (66.8%), the global female LFPR average of 55%, and the female LFPR in Pacific countries including Papua New Guinea (60.5%), Solomon Islands (60.4%), Vanuatu (61.4%) and Palau (58.2%) (Pacific Community August 2017). 17 Republic of the Marshall Islands. 2018. Gender Equality: Where do we stand? Republic of the Marshall Islands. Majuro: Ministry of Culture and Internal Affairs. 18 The term ‘hardship’ relates specifically to national poverty measures. Incidence of ‘hardship’ is defined as the proportion o f the population whose expenditure is below a threshold that includes an allowance for minimum food and non-food needs. Page 14 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) required to boost the productivity, competitiveness, and wellbeing of the Marshallese population. The National Human Resource Development Plan 2014-2019 highlights the development of Marshallese talent with capacity to achieve the strategic vision for the nation as articulated in the National Strategic Plan. The Plan aims to ensure that the future of the RMI is steered toward self-sustainability and efficiency by Marshallese, and this can only be achieved by investing in their people. The President of the RMI has established a Cabinet Committee on ECD (CC) to provide high-level leadership and guidance for the RMI’s flagship ECD Program. 22. The Ministry of Culture and Internal Affairs (MOCIA) has a relatively small budget (below US$2.5 million) and it is entirely funded through government general revenue. MOCIA covers a wide range of areas, such as community development, historic preservation, election and voters’ registration and ID cards, among others. C. Relevance to Higher Level Objectives 23. The proposed Project is in line with three of the four Focus Areas of the World Bank Group’s Regional Partnership Framework (RPF) for fiscal years 2017-21 for 9 PICs (Report 120479), including the RMI. The RPF’s Focus Areas 1 (Fully exploiting the available economic opportunities) and 2 (Enhancing access to employment opportunities, with key interventions on improving education outcomes) are directly strengthened through interventions in ECD, which in turn improve education outcomes. The Project’s interventions to improve availability and quality of essential health and nutrition services for key target groups such as women and children would directly strengthen health systems (RPF’s Focus Area 3 – protecting incomes and livelihoods). 24. The Project enjoys a very high level of support from the Government of RMI, with the request for the Project coming from the President, and Cabinet members showing interest and commitment to the Project. A High Level ECD CC, established and chaired by the President, includes Ministers of Health and Human Services, Finance, Education, Culture and Internal Affairs, and the Chief Secretary. The CC is intended to guide the direction of the ECD policy and programming in the RMI. The ECD Program Committee chaired by the Chief Secretary is responsible for operationalizing the ECD program. The Project is also aligned with all 10 themes highlighted in the RMI National Strategic Plan 2015-2017 through multiple development objectives, including strengthening health systems, improving education outcomes, and enhancing the capacity of youth and vulnerable peoples to meet their full potential. II. PROJECT DESCRIPTION A. Project Development Objective (PDO) PDO Statement 25. The PDO is to improve coverage of multisectoral early childhood development services. 26. The Project seeks to promote universal coverage of multisectoral ECD services by: (i) supporting the government to expand public sector delivery of essential ECD services; (ii) providing targeted support to increase coverage and intervention intensity of these services for vulnerable early years families; and (iii) strengthening the public sector systems necessary to institutionalize and sustain a multisectoral ECD program. 27. Under the Project, essential ECD services target the period between pregnancy and the transition to kindergarten (at age 5); families with at least one member in this target group will be considered “early years families.” Essential ECD services include: (i) essential RMNCH-N services focused on the first 1,000 days of life between pregnancy and age two; and (ii) essential stimulation and early learning services to children’s cognitive and socio-economic development and facilitate children’s readiness to enter primary school. Vulnerable early years families will be identified using a contextually-adapted hardship targeting mechanism developed under the Project. 28. The PDO will be achieved through four main components: (1) improving the availability and coverage of an evidence-based package of essential RMNCH-N and stimulation services for the first 1,000 days (pregnant and lactating Page 15 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) women and children up to age 2); (2) expanding access to stimulation and early learning services by extending pre-schools to children aged 3-4 years, strengthening an existing program of home visits for vulnerable families and promoting community engagement; (3) introducing a conditional cash transfers pilot for vulnerable early years families as a means to increase uptake of essential ECD services and change behaviors; (4) establishing systems and functions to sustain an effective multisectoral programs and Project management. Because the essential maternal and child nutrition and early stimulation services are largely absent from RMI’s current service package, the Project will focus on leveraging facility and community platforms across components to increase the dose and intensity of these interventions and messages. PDO Level Indicators 29. The achievement of the PDO will be measured through the following PDO-level results indicators: (a) Share of women who have had at least one ANC visit by a skilled provider during the first trimester; (b) Share of children aged 0-2 years who receive well-child visits as per established government guidelines19; (c) Number of families with children aged 0-4 years receiving home visits from parent educators; (d) Share of children aged 3 and 4 years attending pre-school. 19The guidelines will be developed and established during the first year of implementation as part of the TA to develop the benefits package Page 16 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Table 4: Proposed Project Strategies and Target Beneficiaries Early years families Targeted vulnerable early years families RMI (in Majuro and Ebeye assessed as vulnerable using local targeting criteria) population Pregnant Improve coverage of facility-based care for pregnant women and Improve coverage of cash transfers to incentivize uptake of women newborns in hospitals/clinics in Majuro and Ebeye, with gradual optimum pregnancy, delivery and post-partum behaviors. Public awareness and social and behavioral communication campaigns to deliver information and roll-out through outreach and in OIs. Services include: newborns - Early and full quality ANC, ante-natal nutrition, counselling on healthy diet and appropriate weight gain - Routine care for labor and childbirth - Identification of high risk pregnancies (obesity, hypertension, etc.) and management of complications - Early and Essential Newborn Care - Family Planning - Birth registration - Transportation costs for OI families to deliver in Majuro and Ebeye* as needed Children Improve coverage of RMNCH-N and stimulation services through Improve coverage of cash transfers to incentivize health service 0-2 years well-child visits at hospitals / clinics in Majuro and Ebeye, with utilization, participation in monthly community events, and uptake gradual roll-out through outreach and to OIs. Services include: of optimum behaviors for child growth and development. - Well-child visits including immunization, monitoring growth, promotion Improve coverage and quality of home-based parental support of optimal infant and young child feeding and development; promotion program in Majuro and Ebeye.* Services provided during home of early stimulation and learning visits include: - Micronutrient supplementation and deworming - Support for positive parenting/caregiving and nurturing environment for - Prevention, detection & treatment of childhood illness stimulation, mental health and wellbeing; - Screening for developmental delays and promote optimal ECD behaviors - Promotion of maternal, infant, and young child health and nutrition Psychosocial stimulation; Children Improve coverage of child health services at hospitals and clinics in Improve coverage of cash transfers to incentivize health and 3-4 years Majuro and Ebeye, with gradual roll-out through outreach and OIs. education service utilization, participation in monthly community Services include: events, and uptake of optimum behaviors for child growth and - Prevention, detection & treatment of childhood illness development. - Well-child visits including monitoring and promotion of growth and Improve coverage and quality of home-based parental support development; promotion of early stimulation and learning program in Majuro and Ebeye.* Services provided during home Expand coverage of public pre-schools for 3-4-year-olds, starting visits include: with 4 schools in Majuro, with phased roll-out in Ebeye and - Support for positive parenting/caregiving, mental health and wellbeing; selected OIs. Services include: - Promotion of maternal, infant, and young child health and nutrition - Play-based learning and simulation - Psychosocial stimulation; - Parental engagement and education *Activities will begin in Majuro and Ebeye and may expand to select other locations based upon need and agreement of government and the World Bank. Page 17 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) B. Project Components 30. This Project consists of four components, which are briefly described in the following paragraphs (see Annex 2 for a detailed description) as follows: - Component 1: Improve coverage of essential RMNCH-N services; - Component 2: Improve coverage of stimulation and early learning activities; - Component 3: Social assistance for early years’ families; and - Component 4: Strengthening the multisectoral ECD system and Project management Component 1: Improve coverage of essential RMNCH-N services (Total: US$4.23 million, of which IDA: US$3.66 million, Government: US$0.57 million) 31. Component 1 aims to improve the availability and coverage of an evidence-based package of essential RMNCH- N and stimulation services for the first 1,000 days (pregnant and lactating women and children up to age 2). Adolescent girls, women of reproductive age and children aged 2-5 years will be secondary target groups, with interventions for these populations incorporated in an opportunistic manner and/or in later stages of Project implementation. The component seeks to both strengthen the package of services provided and alleviate supply- and demand- side barriers to the use of this package of services. The first two years of the Project will focus on alleviating key pressure points to ensure adequate coverage of a revised and evidence-based package of RMNCH-N services in the Majuro/Ebeye Hospitals. The component will also support a suite of technical assistance (TA) activities to identify strategic shifts in service delivery in order to inform further scale-up beyond the first two years. 32. The component has two sub-components, one aimed at strengthening stewardship and management of health administration and the other at directly strengthening service delivery. Each sub-component will have four dimensions: (a) RMNCH-N service package; (b) human resources; (c) equipment and supplies; and (d) data and information. Social and behavior change communication (SBCC) activities will be financed under component 1 and other components as summarized in Table 5. Table 5: Activities supported in component 1 Dimension Sub-component 1.1 Sub-component 1.2 RMNCH-N Service • TA to define essential service package and • Support MOHHS in the delivery of revised RMNCH-N Package delivery options package • Supply-side readiness assessment • Health Financing Systems Assessment Human • Human Resource Needs Assessment • Contract service delivery providers (health facility Resources • Development of capacity building and staff) to optimize number and skill mix training packages • Delivery of comprehensive training and capacity building Equipment and • TA on forecasting, purchasing, • Small equipment and supplies to ensure readiness Supplies procurement, and commodity to deliver RMNCH-N package management Data and • Development/revision of databases to • Minor upgrading of information technology Information meet monitoring and evaluation (M&E) hardware and software to improve record keeping needs associated with revised RMNCH-N and decision making package 33. Sub-component 1.1: Strengthening MOHHS management and stewardship capacity to deliver essential RMNCH- N services (IDA: US$ 1.85 million; Government: US$ 0.06 million). The objective of this sub-component is to strengthen the management and stewardship capacity of the MOHHS to scale up access to the package of essential RMNCH-N services. Under this sub-component the Project will finance: (i) a suite of TA activities to define an essential RMNCH-N Page 18 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) package that is relevant to the RMI disease burden (including the identification, counselling, and management of obesity and NCDs in pregnancy, as relevant), assess supply-side readiness to deliver the package and recommend strategic shifts in service delivery needed to improve coverage and utilization; (ii) a human resources mapping, needs assessment and strategic plan focusing on the delivery of the essential RMNCH-N package, TA to develop a performance management system and the development of training and coaching packages as identified in the needs assessment; (iii) TA on forecasting, purchasing, procurement, and commodity management, as needed; (iv) rapid assessment of health management information systems (HMIS) needs to monitor RMNCH-N utilization and outcomes, including identification of gaps in the existing HMIS; and (v) development of materials for MOHHS to effectively deliver SBCC. 34. Sub-component 1.2: Enhancing delivery of essential RMNCH-N services (IDA: US$ 1.81 million; Government: US$ 0.51 million). The objective of this sub-component is to scale up access to and coverage of a package of essential RMNCH- N services as well as simulation and early learning services for young children and their caregivers. Under this sub- component the Project will finance: (i) support to MOHHS in the delivery of select RMNCH-N Services; (ii) support to MOHHS to contract service delivery providers and achieve a more optimal number, distribution, skills/skills mix, and performance of health care professionals required to effectively deliver the RMNCH-N service package; (iii) procurement of small equipment (including anthropometric measurement equipment), materials, pharmaceuticals/commodities, in order to meet standards of readiness to deliver the basic essential RMNCH-N package; (iv) filling in gaps in the information technology system infrastructure (hardware, software, and training) to monitor RMNCH-N patient records and service utilization, manage stock, and assess performance; and (v) social and behavior change communication activities identified for delivery through MOHHS. Component 2: Improve coverage of stimulation and early learning activities (Total: US$3.79 million, of which IDA: US$3.16 million, Government: US$0.63 million) 35. Component 2 aims to improve children’s cognitive and socio-emotional development and facilitate children’s readiness for on-time transition to primary school through expanding access to stimulation and early learning services. In the absence of a national program for children under five years old, component 2 will work with the Ministry of Education, Sports and Training (MOEST) to strengthen their mandate and capacity to implement and scale up two interventions focused on improving the school readiness of children. This component will strengthen existing service platforms through the delivery of caregiver education home visits to the most vulnerable families20 with children aged 0 to 4 years, and the provision of public pre-schools for 3- and 4-year-old children. Component 2 has two sub-components, one aimed at strengthening stewardship and management capacity of Government for this sub-sector and the other aimed at directly improving delivery of stimulation and early learning services. 36. Sub-component 2.1: Strengthening MOEST management and stewardship of ECD services (IDA: US$1.33 million; Government: US$0.06 million). The objective of this sub-component is to carry out a program of activities designed to strengthen the capacity of the MOEST to manage early childhood development programs, including: (i) conducting assessments of existing capacity and developing plans and strategies for strengthening this capacity; (ii) reviewing and strengthening the regulatory framework for early childhood development; (iii) conducting capacity assessments of the human resource and venue requirements for public pre-schools, and preparing plans for establishing and operationalizing public pre-schools; (iv) developing training plans for MOEST staff to provide management and stewardship of ECD services; and (v) development of inputs for MOEST’s SBCC activities. 37. Sub-component 2.2: Enhancing delivery of stimulation and early learning activities (IDA: US$1.83 million; Government: US$0.57 million). Activities under this sub-component will focus on carrying out a program of activities designed to strengthen the MOEST’s delivery of early childhood development stimulation and learning activities, including: (i) improving existing, and developing new, resources for early stimulation and learning activities including 20 See component 3 for more details. Page 19 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) curricula and training programs; (ii) recruiting, maintaining, and training service delivery providers (e.g. teachers, teacher aides, and home visitors) to deliver early stimulation and learning activities; (iii) procuring and producing materials, facilities and equipment necessary for the delivery of early stimulation and learning activities; (iv) supporting an increase in the number and quality of home visits conducted under the Recipient’s caregiver education home visit Program; (v) identifying, preparing, and equipping venues for public preschools; and (vi) delivering SBCC activities through MOEST. Component 3: Social assistance for early years’ families (Total: US$3.46 million, of which IDA: US$2.91 million, Government: US$0.55 million) 38. Component 3 aims to introduce a conditional cash transfer (CCT) pilot to modify care practices and behaviors and promote uptake of ECD services. Cash transfers would not only directly address financial barriers to accessing key ECD services (e.g., transport and opportunity costs)21, but also be instrumental in addressing cultural behaviors and motivational barriers to accessing health and education services in the longer term. This component would also begin the process of building up a social assistance system in the RMI to drive the ECD agenda. Component 3 has two sub- components, one aimed at providing TA to establish the social assistance system, and the other aimed at the provision of cash transfers to beneficiary families. There are a number of climate-related advantages to the interventions being financed through the project. Under this component for Social Assistance, the social registry of vulnerable households being developed can be used to help target resources to poor and vulnerable families with young children and pregnant women who are most prone and disadvantaged to natural disasters. This will ensure that limited resources are well targeted and disbursed in a timely manner in the wake of disasters. While the pilot activities as initially envisaged are limited to Majuro and Ebeye, expansion to other geographies may be possible based upon need and mutual agreement of the Government of RMI and the World Bank (WB). 39. Sub-component 3.1: Strengthening Government of RMI’s capacity to establish and deliver social assistance program for ECD (IDA: US$1.41 million; Government: US$ 0.13 million). This sub-component will finance a suite of TA activities to support the development of (i) a registry of program beneficiaries; (ii) a sound management information system (MIS) for enrollment, compliance verification of conditionalities, payments of the CCT pilot, and case management; (iii) a grievance redress mechanism (GRM); (iv) setting out the guidelines for an M&E framework; (v) a communications strategy for the social assistance program including SBCC, and the implementation of it; (vi) recruitment and contracting of service delivery providers (program officers) to implement the program; and (vii) support to administrating the program in Majuro and Ebeye including a training strategy and plan for MOCIA staff and field officers. 40. Sub-component 3.2: Provision of cash transfers to early years’ families in selected areas (IDA: US$1.5 million; Government: US$0.42 million). Families in selected areas of Majuro and Ebeye with pregnant women and children aged between 0-59 months who are facing hardship would be eligible to enroll and benefit from the program. During the Project life, the CCT pilot will aim to target the most vulnerable families living in Majuro and Ebeye, approximately ten percent (10%) or other proportion agreed on between the Government of RMI and the Bank. The program will develop a localized vulnerability and hardship criteria, to reach at least 1000 families out of the total number of poorest total families living in the target areas, by developing a localized vulnerability and hardship criteria. To determine the most relevant hardship and vulnerability indicators for targeting purposes, the Project will explore developing a simplified Family Assessment form using key welfare indicators taken from the Household Income and Expenditure Survey (HIES), appropriate to the Marshallese context, during the first year of the Project preparation. The payments will be channeled to the mother or caregiver of the children. The payment amount will be set at a level that accounts for the travel and opportunity costs faced by families, while also providing an incentive to use services for the benefit of children. Cash transfers will be paid every two months to provide regular and predictable transfers to families and thus smooth consumption. A base level of US$30 will be provided to the families plus a bonus amounts of US$3 up to a maximum of 3 children, ‘conditional’ on families being enrolled in the program and attending the predetermined schedule of health 21 ANC visits, vaccinations and growth monitoring visits are free of charge. Page 20 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) facility visits on a regular basis and attendance of ECD education sessions. The program will start with soft conditionalities, for the first year of program implementation until capacity is strengthened and tested, including the development of the MIS and Memoranda of Understanding (MOUs) with clear roles for MOCIA, MOEST, MOHSS, Majuro Atoll Local Government (MALGOV) and Marshall Islands Social Security Administration (MISSA). Given that banking and financial services are limited in RMI, the program will use the banking services being offered by the Bank of Marshall Islands (BOMI), and all beneficiaries will be made electronic payments into their bank accounts. In its initial phase, the program will pilot the cash transfer model in Majuro and Ebeye, followed by close third-party program monitoring through process evaluations, spot checks and an impact evaluation after the first complete year of program implementation. The program will be managed by the MOCIA’s Community Development Division and has the potential to be expanded to other areas based upon agreement of the Government of RMI and the WB. Component 4: Strengthening the multisectoral ECD system and Project management (Total: US$ 3.44 million, of which IDA: US$3.27 million; Government: US$0.17 million) 41. Component 4 will finance the systems functions and activities necessary to sustain an effective multisectoral ECD program and project management. The system functions include: (a) development of a multisectoral national ECD strategy and approach to program implementation; (b) development of a national monitoring, evaluation, and learning framework and implementation of the system; and (c) the preparation of a national communication strategy for ECD and the delivery of public awareness and SBCC campaigns. The component will support the OCS in leading and coordinating an ECD program based on evidence-based best practice through TA activities and support for operational costs. It will aim to increase program effectiveness by: ensuring line ministry activities are underpinned by a strategic approach to program implementation; creating and using data for decision-making; and harmonizing communication activities and messages across various channels. 42. Sub-component 4.1: National Multisectoral ECD Strategy and Governance (IDA: US$0.75 million; Government: US$0.03 million). Sub-component 4.1 will finance TA to develop RMI’s National Strategy for ECD. The strategy will define clear objectives for the national ECD program, describe key activities and interventions, and clearly delineate the roles and responsibilities of the main actors and governance mechanisms. It will further support OCS and the CC in leading ECD program governance and coordinating implementation across key line ministries, such as Ministry of Finance (MOF), MOEST, MOCIA and MOHHS. This sub-component will finance background assessments (e.g. food fortification, nutrition- sensitive food systems, etc.), TA, and operational costs needed to develop the strategy and conduct periodic implementation reviews, as per agreed governance arrangements. 43. Monitoring, Evaluation and Learning (MEAL): Sub-component 4.1 will also finance the development and operationalization of a comprehensive ECD monitoring, evaluation, and learning (MEAL) framework. Sub-component 4.1 will finance a MEAL Coordinator and monitoring of child development outcomes in cohorts over time, either through surveillance methods or appending appropriate child health, nutrition, and development modules to population-based surveys, as feasible22. The sub-component will finance TA to each line ministry to conduct rapid/process/qualitative assessments during implementation, including beneficiary assessments of knowledge and practice. 44. Sub-component 4.2: ECD Awareness and SBCC Campaign (IDA: US$0.45 million; Government: US$0.05 million). This sub-component will finance communications, advocacy, and awareness- raising activities for the ECD program. A centralized approach to the development of communications and advocacy materials is intended to promote linkages across the components and ensure consistency of messages. The sub-component will finance a SBCC and Advocacy Coordinator; and development of a SBCC strategy and associated campaign content intended to increase the intensity of 22Including ongoing discussions to assess anthropometric status and child development in a subset of the 2019 Household Income and Expenditure Survey (HIES) sample to use as a project baseline. Page 21 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) intervention and exposure to campaign messages. The SBCC and Advocacy coordinator will work with the relevant line ministries to ensure buy-in and consistency of messages and activities across channels. 45. In addition, a robust, contextually/culturally/linguistically relevant SBCC strategy and associated campaign content will be developed to increase the intensity of intervention and exposure to campaign messages. It is anticipated the SBCC will be comprehensive and multi-sectoral and include elements such as antenatal and early childhood health and nutrition, positive parenting and nurturing care, and others. The development and coordination of SBCC activities for ECD will be the responsibility of the OCS with support from the ECD PIU and SBCC and Advocacy Coordinator. Sub- component 4.2 will support the development of the SBCC strategy and campaign content; delivery of SBCC through mass media channels; and cross-sectoral coordination and monitoring. Each implementing line ministry will be responsible for implementing SBCC activities through their respective channels (see Table 6). Attention will be paid to reinforcing nutrition and stimulation messages across components 1 and 2. Table 6: SBCC Activities and Channels Across Project Components Component Activities and Channels Component 1 • Production of materials for the health sector; training of health personnel in delivery of the component 1 SBCC package • One-to-one interpersonal communication during ANC, deliver, postnatal care, and well/sick child visits • Group interpersonal communication at health facilities and in communities Component 2 • Production of materials for the education sector; training of education personnel in delivery of the component 2 SBCC package • One-to-one interpersonal communication during home visits • Community-based activities for home visit beneficiaries • Group interpersonal communication at kindergartens Component 3 • Production of materials for MOCIA; training of cash transfer personnel in delivery of the component 2 SBCC package • Community gatherings linked to cash transfer payouts Component 4 • Development of SBCC Strategy • Development of SBCC content for all channels • Development of SBCC monitoring, supervision, and coaching guides • Development of social and community mobilization approaches • Mass and social media campaigns • Social mobilization activities • Multisectoral ECD Community gatherings • Targeted ECD advocacy to improve the enabling environment 46. Sub-component 4.3: Project Management (IDA: US$2.07 million; Government: US$ 0.09 million). A PIU will be established with specific responsibilities to support and coordinate implementation of Project activities. The PIU will be supported by expertise, satisfactory to the Bank, within the Office of the Chief Secretary or the MOF’s Central Implementing Unit (CIU) for FM, procurement, safeguards, communications, and monitoring and evaluation. The sub- component will finance (i) external consultancies required for ongoing Project staffing; (ii) technical consultancies required for adherence to program operations and procedures; (iii) office and other equipment; (iv) training for PIU and CIU staff, as needed; and (e) travel and operational costs. Detailed overview of the ECD PIU and multi-sectoral coordination is provided in Annex 1. Project Cost and Financing 47. The Project will be financed by an IDA grant using the Investment Project Financing lending instrument, and an Page 22 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) amount of US$13 million has been allocated for the Project. Counterpart contributions include staff time, office space, utilities and supplies, secretarial assistance, and other in-kind contributions funded by Government. In addition, local ECD Project officers in each line agency as well as contracted service delivery providers will be included in the Government’s payroll in the latter stages of the Project in order to institutionalize capacity and enhance the sustainability of the program. Project Preparation Advance (PPA) for US$925,000 was signed in July 2018 for carrying out activities relating to the preparation of the Project, its effectiveness and implementation readiness and to support the preparation of strategies, studies, and documents required for Project implementation. Expenditures incurred under the PPA until the effectiveness of the Project will be recovered from the Project funds. Table 7 provides the expected Project financing details. Table 7: Project Financing Project Costs IDA Financing Counterpart Project Components (US$) (US$) funding (US$) 1. Improve coverage of essential RMNCH-N services 4,230,000 3,660,000 570,000 1.1 Strengthening MOHHS management and stewardship 1,910,000 1,850,000 60,000 capacity to deliver essential RMNCH-N services 1.2 Enhancing delivery of essential RMNCH-N services 2,320,000 1,810,000 510,000 2. Improve coverage of stimulation and early learning 3,790,000 3,160,000 630,000 activities 2.1 Strengthening MOEST management and stewardship 1,390,000 1,330,000 60,000 of ECD services 2.2 Enhancing delivery of stimulation and early learning 2,400,000 1,830,000 570,000 activities 3. Social assistance for early years’ families 3,460,000 2,910,000 550,000 3.1 Strengthening Government of RMI’s capacity to 1,540,000 1,410,000 130,000 establish and deliver social assistance program for ECD 3.2 Provision of cash transfers to early years families in 1,920,000 1,500,000 420,000 selected areas 4. Strengthening the multisectoral ECD system and 3,440,000 3,270,000 170,000 Project management 4.1 National Multisectoral ECD Strategy and Governance 780,000 750,000 30,000 4.2 ECD Awareness and SBCC Campaign 500,000 450,000 50,000 4.3 Project management 2,160,000 2,070,000 90,000 Total Project Costs 14,920,000 13,000,000 1,920,000 C. Project Beneficiaries 48. The primary beneficiaries of the Project are the pregnant women, children under the age of 5 (0-59 months) and their caregivers facing hardship, and women of reproductive age in the RMI. The Project will finance activities in the entire RMI, including all populated atolls and islands of the RMI, although some piloting will be done in targeted locations in the early stages of the program. Secondary beneficiaries of the Project are the implementing agencies and their staff - Government, private and non-governmental organizations - receiving TA and capacity building to strengthen the provision and M&E of ECD services in the RMI. 49. Gender. The proposed Project will contribute to closing gaps in women’s endowments in health outlined in the World Bank Group Gender Strategy and the East Asia Pacific Regional Gender Action Plan, with a focus on reducing Page 23 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) maternal morbidity and mortality and childhood stunting for poor and vulnerable women and children. In RMI, gaps in women’s endowments in health and education contribute to poor MCH and nutrition, as well as poor child development outcomes. Poor maternal health and nutrition increase the risk of overweight, obesity, and diet-related NCDs that present risks to maternal and infant survival. Further, poor maternal nutrition perpetuates an intergenerational cycle of malnutrition, whereby children of malnourished mothers (defined as underweight or maternal short stature) are at increased risk of low birth weight and child stunting. These risks are amplified for teenage mothers, whose young age further increases the likelihood of high risk pregnancies and undernourished babies. The project support for increasing access and utilization of early, quality antenatal care and skilled delivery will help to minimize these risks to women’s own health and that of the next generation. 50. The low availability, quality, and utilization of essential health services is a key driver of these poor outcomes. The Project will finance activities to overcome supply-side barriers to accessing key evidence-based reproductive, maternal, and child health interventions that have demonstrated effectiveness in improving these outcomes. The Project will support MOHHS to define and scale up a package of essential RMNCH-N services, supporting investments in the human resources, service delivery, equipment, and data systems needed to deliver these and with improved quality. The Project will also support operational costs for new service delivery modalities to reach vulnerable women with these services on the Outer Islands as well as through community outreach. 51. To further stimulate demand for essential RMNCH-N services, the Project will provide CCTs to women with high vulnerability (e.g. low income, assets, and/or endowments) in order to increase their beneficiaries of the parenting interventions and with social assistance in order to close gaps in the outcomes for their children. Some concerns have been raised about the social implications of providing this type of assistance to families. The social assessment will pay particular attention on the socio-cultural and intra-household considerations of providing cash directly to women in order to minimize risks of gender-based violence and maximize the likelihood of using cash for investments in human development. The Project will measure its ability to close the gaps in these outcomes by monitoring the increase in early stages of pregnancy (first trimester) and the number of female beneficiaries receiving regular cash transfers. D. Results Chain 52. Figure 2 presents the results chain for the Project, showing the expected outputs for each component and anticipated outcomes at the individual (child) and system levels. In summary, the Project will improve the life chances of a child born in RMI so that when (s)he is born, (s)he benefits from proper health and nutrition as well as early stimulation, has opportunities for early learning before primary school, and is protected from economic stresses at home through better social protection; all of which will better enable her/his access to essential services and opportunities throughout her/his life. Page 24 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Figure 2: Theory of Change for the Early Childhood Development and Nutrition Project Page 25 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) E. Rationale for Bank Involvement and Role of Partners 53. As discussed earlier, the Project is aligned with three of the Focus Areas of the RPF. Education outcomes, as referenced in Focus Areas 1 and 2 of the RPF, are strongly predicted by the time a child enters the first year of primary school, and are strengthened through interventions focused on health, nutrition and early stimulation. Addressing focus Area 3, the Project intends to address needed improvements in the availability and quality of essential health and nutrition services for pregnant women and children. The Project is also aligned with the new global initiative of the WB, the Human Capital Project, which seeks to support governments to identify their constraints to developing human capital and explore solutions to address those constraints through improved health and education outcomes. 54. The Government of RMI is committed to ensuring that all partners engaged in ECD work closely and in alignment. The US has been a major funder of the health and education sectors in the RMI since the CFA agreement was signed in 1983, although as previously mentioned, this funding is set to decrease substantially after the CSGs cease in 2023. UNICEF is a key partner and has carried out significant formative research on the health and nutrition of children as well as supporting immunization programs. UNICEF’s work in the RMI is co-financed by the Department of Foreign Affairs and Trade of Australia and the Asian Development Bank (ADB). The WB has been coordinating closely with UNICEF to agree on areas in which each organization has a comparative advantage and relevant resources under the new ECD program. The ADB is supporting teacher training at the primary level through their Improving Quality of Basic Education Project. F. Lessons Learned and Reflected in the Project Design 55. The Project design incorporates lessons learned from global best practices and research in ECD. This will be the first WB engagement in the human development sectors in the RMI, but lessons from recent WB engagement in the Pacific in piloting and delivering a community-based model of early stimulation and learning for caregivers and young children has also been incorporated into the design, and results from the RMI ICHNS in 2017 were important in identifying the need for a universal targeting approach. Some of the international best practice and lessons learned informing design are listed below: (a) Multisectoral approach to ECD. ECD requires multisectoral collaboration, which provides challenges to effective implementation of activities and development of policy. Chile Crece Contigo provides lessons learned after 10 years of program implementation about considerations for ensuring the different sectors work together, including recognizing the expertise each sector brings to the table, identifying clear and separate functions of each actor, involving all stakeholders from the beginning, and developing an integrated system that spans all participating sectors. The institutional arrangements for oversight and implementation of this Project have been designed with these lessons in mind and in consultation with all sectors involved in the Project. (b) Selection of beneficiaries. The period from conception to a child’s second birthday (the first 1,000 days) is the most critical window of opportunity for interventions in health and nutrition. Stunting often starts in utero, therefore maternal nutrition interventions are critical. Maternal undernutrition is a contributing factor in an estimated 20 percent of maternal deaths and contributes to adverse pregnancy outcomes, childhood mortality and stunting. Early stimulation by parents and caregivers is also critical in this period. Combining health and nutrition interventions with early stimulation at this stage of a child’s development has been shown to be optimal for physical and cognitive development. From the age of three to five, as children prepare to enter primary school, more formal early learning and socialization opportunities outside of the home become important. (c) Focus on strengthening facility-based delivery of RMNCH-N services. Although the global evidence from successful ECD programs places great emphasis on strengthening outreach and community-based delivery of RMNCH-N services, this Project will initially focus on strengthening facility-based delivery of these services in the hospitals and clinics in Majuro and Ebeye. With nearly 75 percent of the total population living in Majuro and Ebeye and high population density (295 per km2 in Majuro; 11,000 people over 0.33 km2 in Ebeye), physical access to the hospitals and clinics is high. Page 26 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) The main challenges to service delivery at present include the availability and distribution of human resources, coordination across providers and adequate supervision. In this context, there is a clear opportunity, at least in the initial phase, to maximize coverage by quickly and effectively strengthening service delivery at the facility level. TA carried out in the initial phase of the Project is expected to develop strategies for strengthening outreach and community-based delivery in the later stages of the Project. (d) Early Stimulation and Learning. Extension of the kindergarten to include 3 to 4-year-old children aims to provide public pre-school to all children. Evidence from the Pacific, Indonesia and elsewhere show improved development outcomes for those children with some form of early education prior to beginning primary school. Home visits have strong evidence of impacting parental interaction with their children in Jamaica and multiple studies in the United States, with long-term gains observed in stunted children on cognitive, social, educational and mental health benefits, and increased wages. (e) Communication and behavior change. At the household and community level, SBCC is central to changing behaviors. Research from a variety of contexts demonstrates that community-based communication can effectively change behavior in a cost-effective manner. Likewise, practical coaching sessions have the power to change behavior after a relatively short period of time. The Project will design practical sessions to reinforce parents’ and caregivers skills in quality interactions to build self-confidence and agency in parents/caregivers to engage successfully with their children. Beneficiary access to contextualized communication and mass media messages can rapidly improve feeding practices at scale. In Bangladesh, for example, delivery of a community-based communications package, developed with assistance from Alive and Thrive, was associated with more than 30 percent improvement in key indicators – exclusive breastfeeding and consumption of a diverse diet – over 3 years. III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 56. The MOF, MOHHS, MOEST and MOCIA and their relevant divisions will be the implementing agencies for the core Project activities as follows: (a) MOHHS for component 1; (b) MOEST/PSS for component 2; (c) MOCIA for Component 3; and (d) MOF and OCS for component 4, as well as the disbursement and replenishment of the program’s Designated Account (DA). A PIU will be established within OCS responsible for overall coordination, results monitoring, and communicating with the WB on Project implementation. As with other WB projects, the CIU in MOF will support implementing agencies, as required, in safeguards and fiduciary functions associated with the Project implementation. Although the CIU is not currently a formally established entity, MOF maintains essential expertise such as financial management, safeguards, and procurement, within the CIU to provide implementation support for donor financed project. 57. The highest level of the program’s governance is the High Level ECD Cabinet Committee (CC), established by the Cabinet in June 2018 to provide high-level strategic leadership and guidance for the RMI’s flagship ECD Program and to take high-level policy decision related to ECD. The CC is chaired by the President and comprises the following ministers: 1) Minister of Health and Human Services, 2) Minister of Education, 3) Minister of Culture and Internal Affairs, 4) Minister of Finance. 58. The CC will be supported by an ECD Program Steering Committee (PSC), comprising of heads of the relevant line ministries (see Annex 1) and chaired by the Chief Secretary; the PSC will provide oversight, coordination, and implementation support for the RMI’s flagship ECD Program and other efforts in this area. An ECD Working Group will be formed, chaired by the ECD Program Officer, that will include relevant technical focal points from the implementing line ministries and other relevant agencies (e.g. Economic Policy Planning and Statistics Office, national training institute), staff from the WB-financed PIU, and other stakeholders. The ECD Working Group will facilitate coordination across the RMI’s ECD program and will provide technical inputs to the PSC. The PSC was established by Cabinet in December 2018. Page 27 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 59. The PSC will provide Project oversight, coordination and implementation support with the ECD Program Officer, as the Secretariat reporting to the Chief Secretary. The PSC will meet quarterly and work closely with all development partners supporting ECD related efforts in the RMI and provide regular reports and updates to the CC on ECD. As this is a nascent program, the PIU with TA from international experts to establish the program, with the understanding that many of these functions will be transferred to line ministry staff in years three to five of the Project. The PIU will include (a) an ECD Program Officer, internationally recruited; (b) an M&E expert, internationally recruited; (c) an SBCC and Advocacy coordinator, international recruited; and (d) locally hired support staff. The PIU’s functions will be directed by the OCS. The PIU will be responsible for all core functions of the Project’s implementation, management and the coordination of activities of the implementing agencies. Additionally, each line ministry will have one internationally recruited ECD Coordinator plus one locally recruited ECD Coordinator hired as PIU staff to sit within the respective line ministries of MOHHS, MOEST, and MOCIA. The International ECD Coordinator will work closely with the line ministry’s local ECD Coordinator(s) to provide TA to the implementation of the Project’s activities and build capacity of the sectoral ministries. Ensuring that local staff take over ECD program coordination responsibilities within the line ministries at a later stage of the Project is a key goal of the Project and will be an explicit objective in the Terms of Reference (TORs) of the international advisors. ECD Coordinators, both international and local, will jointly report to the relevant line ministry Secretary and the ECD Program Officer/Chief Secretary. B. Results Monitoring and Evaluation Arrangements 60. Progress toward the PDO will be monitored through reporting on the PDO-level and intermediate-level results indicators. A Results Framework with Project-specific indicators and actionable monitoring arrangements has been developed jointly with the MOHHS, MOEST, MOCIA, and other stakeholders. This will be used for monitoring of implementation progress and results of Project implementation. Overall monitoring and coordination of Project activities will be performed by the implementing agencies with the support of the PIU. The PIU will have overall responsibility for M&E of the different components/activities in accordance with the indicators included in the Results Framework (Section VI). The PIU will gather data from the relevant units in the Government. No later than 45 days after each semester (semi- annually), the PIU will submit semester progress reports to the WB, covering all Project activities, including safeguards, procurement and financial summary reports. The Project will also submit its Annual Work Plan and Budget for the WB’s no-objection. 61. An impact evaluation will take place one year after the start of the implementation of the ECD project. The evaluation will provide the necessary information on beneficiary behavior, household dynamics, spending behavior and emerging program impacts which could inform the functioning of the program, and support the national roll-out of the social assistance program. 62. The WB will monitor implementation progress during semi-annual implementation support visits (three implementation support visits will take place during the initial year of implementation, after which they will be reduced to two visits in subsequent years) which will provide a detailed analysis of implementation progress toward achieving the PDOs and include an evaluation of FM and a post-review of procurement activities. During the implementation support visits, the WB will work with the MOHHS, MOEST and MOCIA to obtain feedback on progress and consider any adjustments to ongoing activities. 63. No later than December 2022 (or such other date as agreed with the WB), the PIU, in coordination with MOHHS, MOEST, MOCIA and MOF, will carry out a midterm review of the Project and prepare and furnish to the WB a midterm report documenting progress achieved in the implementation of the Project during the period preceding the date of such report, including the M&E activities performed and setting out the measures recommended to ensure the continued efficient implementation of the Project and the achievement of its Objectives during the period following such date. It will also review this midterm report with the WB on or about a date one month after its submission and thereafter take all measures required to ensure the continued efficient implementation of the Project and the achievement of its Page 28 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) objectives. At the end of the Project, the WB will prepare an Implementation Completion and Results Report, which will include an assessment of the Project by the Government, to evaluate the Project and draw lessons. C. Sustainability 64. The most important factor contributing to the sustainability of the Project is the very high level of political commitment from the Government of RMI as evidenced by the governance arrangements for the project. The Government has provided a very high level of support to the preparation of the Project and has been closely engaged in Project preparation. The Project’s institutional arrangements were also developed with a view to sustainability. For instance, the Project will finance international TA for each of the agencies, who will be supported by locally hired personnel, who are expected to be absorbed into government. 65. The Project design’s emphasis on building on existing systems in health and education and rolling out new systems gradually based on TA will be a key factor in project sustainability. For instance, component 1 focuses on strengthening existing models of RMNCH-N delivery that are already in place in Majuro and Ebeye. Component 2 involves the scaling up of an existing model of home-visits to vulnerable families and the gradual expansion of kindergartens for 3-4-year- olds. Component 4, which is devoted to monitoring, evaluation and learning will help ensure that whether the Project is scaling up existing interventions or introducing new ones, there is an established mechanism to evaluate intervention processes and impacts and modify as appropriate. 66. Financial sustainability is a concern at this stage. Both the health and education sectors are expected to face fiscal constraints in the lead-up to 2023 and beyond, as discussed in the Economic and Financial Analysis below. In preparation for this, the WB will produce a Country Economic Memorandum and Public Expenditure Review in 2020/2021, which will include detailed sectoral analysis of health and education. These reports as well as other TA carried out as part of the Project will analyze areas for efficiency savings within the health and education sectors and options for mobilizing additional resources for the two sectors. IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis Technical Analysis 67. The Project builds on the global evidence surrounding the importance of investing in the early years. Guaranteeing that every child has adequate access to education, health, nutrition and protection in the early years ensures that they have the required foundations for developing skills and are ultimately able to access jobs in the future (World Bank 2018). Improving these outcomes, especially in the first 1,000 days, is critical for addressing the World Bank Group twin goals of reducing poverty and boosting shared prosperity. The returns to investments in children’s early years are substantial, particularly when compared to similar investments made later in the life cycle (Heckman and Masterov 2007). Intervening during early childhood clearly has the potential to mitigate the negative effects of poverty and promote equitable opportunities and better outcomes later in life (Heckman 2008). The Project addresses the key areas of the WB’s Investing in the Early Years Conceptual Framework while strengthening the system to ensure continuum of care and coordination of services. 68. Delivering ECD and nutrition services through a multi-sectoral program approach. The program will employ a multi-sectoral response to achieving improvements in children’s physical, cognitive, and non-cognitive development. The program will consist of two phases, initially leveraging the existing services and platforms, sequentially expanding the scope and quality of early years services, and simultaneously strengthening the institutions and systems necessary to institutionalize the service delivery platforms. Over time, these newly developed platforms will stimulate demand and Page 29 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) behavior change among families and communities. The multi-sectoral program approach allows for adaptive learning of different service delivery approaches and their applicability to the RMI context. 69. The provision of CCTs would serve to improve the demand for these services and therefore compound the development impacts associated with their provision. The economic benefits of this type of intervention are expected to be twofold: (a) by incentivizing the uptake of ECD and nutrition services, this will improve children’s educational and health outcomes, and therefore projected wage earnings over their life cycle; and (b) by providing direct monetary transfers to families, there will be an immediate impact on poverty rates at the household level. The costs are derived from the actual cash transfers, associated administrative costs for their provision, and potential inflationary effects for non-beneficiaries (higher costs for food items, for example). World Bank Value Added 70. The WB has extensive experience in addressing ECD and nutrition issues and has gained considerable experience in preparing multi-sectoral early years programs, focusing on health, nutrition, education and social protection. The WB brings global knowledge and experience to the development of nutrition-sensitive operations which use an integrated approach to improving health, nutrition and child development outcomes. These integrated approaches involve the use of community-based interventions linked to strengthening access and delivery of services and are supported by social and behavioral change interventions (Indonesia, Madagascar, Cote d’Ivoire). The use of cash transfers in these operations is also becoming an increasingly popular instrument for nudging family spending towards nutritious and healthy choices (Indonesia, Myanmar). The WB has also amassed considerable regional experience in the Pacific, with on-going health and nutrition operations in PNG and Solomon Islands. The WB is a pioneer in ECD and early learning through the Pacific Early Age Readiness and Learning Program which covers three PICs, including Tonga, Tuvalu and Kiribati. The WB has also recently prepared a lending operation in Tonga (Skills and Employment for Tongans) that includes a CCT for secondary school students, which is in addition to its long-standing TA engagement in the Pacific on social protection, with in- country engagements in Fiji, Tonga and Papua New Guinea. The WB offers predictable, stable financing in a sector which has traditionally been underfunded in RMI. Moreover, the WB’s assistance will be well coordinated with support provided through other development partners, such as Australia’s Department of Foreign Affairs and Trade, and UNICEF, and therefore complement, rather than supplant, existing areas of support. Economic Analysis 71. Global evidence identifies investments in ECD and nutrition as cost-effective as returns on these investments are high (Kilburn and Karoly 2008). Investment frameworks for health and nutrition and meta-analyses of studies measuring the cost-effectiveness of ECD interventions in low income countries and low-middle income countries were used to guide the selection of activities financed by the project and priority was given to interventions with high benefit-to-cost ratios, such as nutrition activities and pre-school services that involve parents. 72. There are several channels through which ECD and nutrition programs accelerate economic growth. Healthy children that participate in ECD programs achieve stronger cognitive and socio-emotional skills and are readier to learn at school. Better educated children, in turn, have higher chances of participating in the labor force. Research shows that children that received early childhood stimulation were more likely to have higher wage earnings when they joined the workforce. In addition to increasing children’s potential to engage in productive activities, ECD programs (particularly pre-school activities) provide custodial care for children and allow parents to join the labor market and engage in income- generating activities, further contributing to economic growth. The economic benefits of ECD and nutrition programs can be leveraged by CCT that enable parents to invest in the human development of their children. 73. Critical data to estimate the economic benefits of investments in ECD and nutrition is not available in the RMI. By and large, nevertheless, the cost of failing to improve ECD and nutrition outcomes is high. This is explained by the negative effect that chronic malnutrition, low coverage of RMNCH-N services and limited coverage of pre-school activities has on Page 30 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) economic growth. It should be noted, however, that the RMI’s small population and remoteness might reduce the expected benefit-to-cost ratio of ECD and nutrition interventions. Rationale for government intervention 74. Public sector provision and financing of ECD and nutrition services are appropriate where market failures clearly exist. In the context of the RMI, these include: the lack of availability of widespread quality public ECD and nutrition services; uncertainty about or lack of information on the benefits of ECD; and imperfect parenting (parents unavailable, unhealthy, or uncaring). The set of ECD and nutrition interventions proposed under the Project are considered public goods with positive externalities. Public financing is needed not only to enhance investments in the productivity of future generations, but also to reduce future health care costs and their potential downside impact on the economy. Public financing and provision are also necessary to improve both the efficiency and equity of service delivery. 75. The private sector does provide certain services in the RMI; however, as the immediate returns are low, there is chronic underinvestment and availability is relatively limited. Pre-school for 3-4-year-olds is only privately provided and covers approximately 5 percent of the population. Those from poor families are less able to access these privately provided services. Moreover, families in the OI are at a distinct disadvantage both in terms of access to information about ECD services and in their ability to access them affordably (service fees are low, but transport costs pose a significant barrier). In addition, it should be noted that evidence shows that public investments in early child development do not crowd out private investments (Berlinski, Galiani, and Gertler 2009; Bastos and Straume 2013). Financial Analysis 76. Macroeconomic forecasts predict continuous economic growth over the next five years, but the RMI’s small and undiversified economy pose risks to the country’s medium-term financial stability. As a result, achieving a balanced budget has been identified as a high priority for the Government of RMI. 77. Article IV consultations highlighted the importance of safeguarding social spending and promoted the use of grant financing. The Decrement Management Plan of 2014 foresees cuts in the social sector’s budget, particularly in the health sector. In 2016, health and education represented the largest share of total government spending (ca. 21 percent each). The Ministry of Culture and Internal Affairs, in turn, represented 2 percent of total government spending (Budget Book 2016-2021). 78. It should be noted that the availability of financial data in the RMI is limited. The low level of disaggregation of budget and expenditure data hinders the performance of financial analyses and represents a significant constraint to more detailed assessments of the financial implications of this Project. Health spending 79. Investments proposed under this Project represent a marginal share of the sector’s budget. With yearly estimated disbursements slightly higher than half a million dollars, the Project would constitute an increment of 2 percent in the health budget. Moreover, these investments will not lead to high incremental costs in the near- or medium-term. Capital investments under the Project will be limited to the purchase of basic equipment. Maintenance of such equipment will only require minor investments, and these will not exert pressure on the budget of the MOHHS. Investments in human resources will represent roughly 60 percent of all investments and include three nurses for Majuro hospital and three nurses for Ebeye hospital, as well as two certified nurse midwives. With 520 public servants in the payroll of the MOHHS, this will represent a 1.5 percent increase in the workforce and contribute to a yearly increase in the sector’s budget of 0.8 percent. Education spending Page 31 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 80. The RMI Multisectoral ECD Project will provide an additional half million dollars to the education sector. Compared to 2016 spending data, this represents an increase of 2.1 percent. Capital investments will be limited to the procurement of basic equipment and the expansion of public elementary schools to cater for children age 3 to 4. The exact impact of these investments on the cost of utilities and the maintenance budget cannot be estimated given the lack of relevant data, but the nature of the equipment (basic equipment with marginal investments in maintenance required) and the small scale of the infrastructure upgrades suggest that the impact will be small. Social protection spending 81. The Social Assistance component of this Project will contribute approximately US$385,000 every year, which represents 16 percent of the MOCIA’s budget. While these investments do not create potential incremental costs in the future, there is a risk that the MOCIA will not have the financial management capacities to administer these funds efficiently and effectively. To mitigate this risk, Project funding will be utilized to cover the running costs and the salaries of the staff required to implement the Project, at least during the first 5 years of implementation. Staff costs, including the salaries of local and international staff as ECD Program Officer, an SBCC and Advocacy coordinator, a M&E coordinator and a program officer, amount to almost one million dollars a year, represent a significant incremental recurrent cost. Building the capacity of the local staff to carry on these activities after the Project finishes will be of utmost importance to ensure the financial and institutional sustainability of these interventions. B. Fiduciary (i) Financial Management 82. An FM assessment of the CIU, which will be responsible for fiduciary aspects, was carried out in accordance with the “Principles Based Financial Management Practice Manual” effective March 1, 2010. Under the Bank’s Directive: Investment Project Financing (Directive), the borrower and implementing agencies are required to maintain financial management systems, including accounting, financial reporting, and auditing systems, adequate to ensure accurate and timely information regarding the Project resources and expenditures. Overall, the assessment found that the FM arrangements satisfy the requirements as stipulated in the Directive subject to implementation of agreed actions and mitigating measures. The CIU in MOF is responsible for the FM arrangements for the whole Project. The CIU is a newly- formed unit and currently has limited capacity. A Finance Manager employed in 2017 is solely responsible for the FM requirements for the current portfolio. With the current staff levels, there is a risk of over-extending CIU’s current resources, which could be a constraint for the implementation of this Project without adequate provision of additional Project support. A dedicated FM Officer for this Project is recommended to be recruited subject to an assessment of the scope of the work required given the complexity of the Project, especially in the administration of sub-component 3.2 on CCTs. The Project Operations Manual (POM) will include a section on budgeting, disbursement, and financial management arrangements. The sharing of services with other WB projects will require processes to ensure that expenditures are properly recorded and documented, and associated funds flows closely monitored. Training on the FM requirements of the Project will be conducted and monitoring of compliance to FM processes will be a regular part of the implementation support visits. Details for Financial Management arrangements are presented in Annex 1. (ii) Procurement 83. Procurement under this Project will follow the WB Procurement Regulations for IPF Borrowers dated July 2016, revised November 2017 and August 2018. Key risks relating to procurement will largely be mitigated with the procurement specialist in the CIU providing support to the Project, although the task of managing and coordinating procurement activities in the Project will fall under the Program Officer and the respective sector Program Coordinators, whose TORs will also include procurement related functions. The WB will provide relevant procurement training and implementation support, and the Systematic Tracking of Exchanges in Procurement (STEP) application will be used to prepare, clear, and update Procurement Plans and conduct all procurement transactions for the Project. Accordingly, all Page 32 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) the procurement activities under the proposed Project will be entered into, tracked and monitored online through the system. On the ground support will be provided by CIU’s procurement specialist while the World Bank is available to provide further support. The POM will include a Procurement Module to guide procurement implementation. Details for procurement arrangements are presented in Annex 1. C. Safeguards (i) Environmental Safeguards 84. Climate risk and disaster screening has confirmed that this Project is not exposed to climate change and geophysical geohazards now or expected to be in the future. However, in case of a disaster, introduction of the social registry of vulnerable families under component 3 can be used to help target resources to families with young children (0-5 years) and pregnant women who are most vulnerable and disadvantaged following natural disasters. This will ensure that limited resources are well targeted and disbursed in a timely manner in the wake of disasters. 85. The Project is classified as Category B and an Environmental and Social Management Framework (ESMF) was prepared in accordance with OP/BP 4.01 (Environmental Assessment). Construction of facilities for ECD and health services are not planned to be financed by the Project. However, the Project will involve use of public buildings in Ebeye and Majuro, some of which may require refurbishment or reconstruction. Hazardous/medical waste from improved health services may create health or environmental risks if not segregated from other waste and managed/destroyed appropriately. The ESMF was disclosed in-country on November 29, 2018, and on the WB’s external website on November 30, 2018. (ii) Social Safeguards 86. The social impacts will be overwhelmingly beneficial and will be targeted at the most vulnerable in the community. Social risks, such as domestic conflicts from cash payments or other incentives, may arise if not adequately considered in project design and delivery. Physical works will be restricted to renovations or reconstruction of existing facilities and no land acquisition or involuntary resettlement will be necessary. World Bank Safeguard Policy OP/BP 4.12 (Involuntary Resettlement) has not been triggered. Safeguards are integrated into project design, such as the consultations and awareness campaigns by the SBCC and other outreach activities as described under Citizen Engagement and elsewhere in the project description (i.e. Table 6). A Grievance Redress Mechanism (GRM) was included in the ESMF, including a feedback loop to inform an adaptive management approach to project delivery. (iii) Other Safeguards 87. Citizen Engagement. During Project preparation, the WB team held a number of focus group discussions with communities and stakeholders in Majuro, Ebeye and Arno, and local governments in Majuro, Ebeye and OI to discuss the proposed Project, and seek advice and guidance on key elements of the Project design, particularly related to access to and understanding of health and early stimulation and learning services, and perceptions on different kinds of social assistance being proposed under the Project. These discussions provided useful insights into challenges and perceptions of the agencies and communities consulted and were used to inform Project design. They discussions led to a more pilot- based exploratory design of Component 3, which would allow the Government of RMI and the Bank to design the cash transfers incrementally. 88. During Project implementation, beneficiary and stakeholder engagement will be an integral part of preparing, implementing and evaluating activities. The Project is designed to incorporate adaptive learning, which will inform modifications to Project activities during the life of the Project for successful scale up of interventions. During Project implementation, stakeholder engagement and monitoring systems will be setup and used to identify successes and issues related to Project activities and will include a feedback system as part of the Project GRM. This integrated approach will form a useful platform for beneficiary and citizen input into adaptation of the Project as it progresses. Page 33 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 89. The Government prepared an ESMF, which includes a strategy for carrying out consultations with beneficiaries once identified. The SBCC and Advocacy Coordinator will be responsible for preparing and implementing the various outreach and engagement activities and integrate the relevant aspects of Citizen Engagement (indicators, data requirements, feedback mechanisms) into the project’s M&E and GRM. (iv) Grievance Redress Mechanisms 90. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. V. KEY RISKS 91. The overall risk rating for implementation is Substantial. The key risks are the: (a) limited technical capacity coupled with high turnover rate in the implementation agency; (b) lack of experience in implementing World Bank projects, including the aspects of procurement and FM; and (c) need to coordinate among various Government ministries and other stakeholders supporting the implementation of the Project, particularly as a multisectoral coordination unit will be set up to implement and monitor activities (d) the Project represents a considerable investment on a per capita basis for RMI. This is also a new engagement for the WB in the Pacific with a multisectoral approach to ECD and nutrition. Lack of prior engagement and the logistical challenges of travel to the country for face-to-face dialogue increase the risks of delay in Project delivery and ineffective Project design. The Bank will need to work closely to establish and sustain a strong relationship with relevant stakeholders. Additional resources may be required for this purpose. The Project aims to mitigate the implementation risks by bolstering the institutional and implementation arrangements (ECD PSC, ECD Working Groups) with technical advice and assistance financed through the Project and housed in the PIU. 92. Institutional capacity risks for implementation and sustainability are Substantial. There is a substantial likelihood that inadequate institutional capacity for implementing and sustaining the operation may adversely affect the PDO. Given that ECD is a completely new sub-sector for all of the agencies concerned, it is inevitable that staff technical skills are inadequate, and staff have limited access to relevant training, supervision and support. The Government has been relying on external consultants to support their operations. The Project’s approach to mitigating the institutional capacity risk is to invest heavily in technical capacity building from early on. The Project will finance international advisors to bring in much needed global knowledge and expertise as this is a new area. A key element of the Terms of Reference for the international advisors is to train and nurture RMI nationals in the different areas of ECD. Past experience with other WB projects has shown that securing good quality and sustained TA inputs is expensive in RMI. The Project’s relatively high cost is partly due to the large TA needs. 93. Fiduciary risk is Substantial. FM and procurement for the Project will be supported by CIU, which was only recently established and hence has limited experience working on WB supported projects. The scale-up of WB financed projects in the RMI increases the number of projects implemented by MOF, overextending their limited project management resources. The FM risk of the Project is assessed as Substantial primarily because of this risk, which could prove a constraint for the implementation of this Project absent additional Project support. In addition, multiple line Page 34 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ministries (MOHHS, MOEST, MOCIA) implementing their respective components further contributes to the complexity of the FM arrangements for the Project. 94. Risks related to procurement are primarily due to the limited experience in government with implementing procurement following WB procedures which is exacerbated by the nature and size of contracts to be processed under this Project. There are multiple implementing agencies for the Project. The MOEST/PSS and MOHHS have varying degrees of experience, including procurement under foreign-assisted projects while MOCIA has undertaken mostly smaller procurements. However, all three sectoral agencies are new to the WB processes and its procurement regulations and procedures. In order to mitigate the above identified risks and strengthen the procurement capacity of the Project, the following measures have been established and agreed to be implemented: (a) procurement specialist in the CIU at MOF to provide TA and support to the Project; (b) the Program Officer and the respective sector Program Coordinators will include in their TORs procurement related functions, among others; (c) Project staff will be continuously provided with relevant procurement training and implementation support by the World Bank; and (d) the STEP system will be used to prepare, clear and update Procurement Plans and conduct all procurement transactions for the proposed Project. . Page 35 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) VI. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Marshall Islands Multisectoral Early Childhood Development Project Project Development Objectives(s) To improve coverage of multisectoral early childhood development services Project Development Objective Indicators RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 To improve coverage of multisectoral ECD services Share of women who have had at least one ante-natal care visit by a skilled provider 34.00 34.00 40.00 45.00 55.00 65.00 during the first trimester (%) (Percentage) Share of children aged 0-2 years who receive well-child visits as per established 0.00 5.00 15.00 25.00 40.00 50.00 government guidelines* (Percentage) Number of families with children aged 0-4 years 85.00 100.00 150.00 250.00 350.00 500.00 receiving home visits from parent educators (Number) Share of children aged 3 and 4 5.00 7.50 10.00 12.50 15.00 25.00 Page 36 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 years attending pre-school (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Component 1. Improve coverage of essential RMNCH-N services Number of health workers trained in maternal, infant, and young child nutrition promotion (or, trained to 0.00 10.00 20.00 30.00 45.00 60.00 deliver a package of essential RMNCH-N services) (Number) Number of RMNCH-N providers undergoing regular performance monitoring 0.00 0.00 0.00 15.00 30.00 40.00 (Number) People who have received essential health, nutrition, and 0.00 2,500.00 5,000.00 10,000.00 15,000.00 19,850.00 population (HNP) services (CRI, Number) Number of children immunized (CRI, Number) 0.00 1,250.00 2,750.00 3,000.00 3,500.00 4,600.00 Number of women and children who have received basic nutrition services (CRI, 0.00 750.00 1,250.00 5,000.00 7,500.00 9,750.00 Number) Number of deliveries 0.00 500.00 1,000.00 2,000.00 4,000.00 5,500.00 Page 37 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 attended by skilled health personnel (CRI, Number) Component 2. Improve coverage of stimulation and early learning activities Number of children aged 3-4 attending kindergarten 238.00 350.00 500.00 650.00 800.00 1,000.00 (Number) Number of girls aged 3-4 attending kindergarten 117.00 175.00 250.00 325.00 400.00 500.00 (Number) Number of teaching aides, parent educators, coaches and MOEST/PSS staff receiving 0.00 20.00 30.00 40.00 55.00 70.00 training under the project (Number) Component 3. Social assistance for early years' families Beneficiaries of social safety 0.00 200.00 400.00 600.00 800.00 1,000.00 net programs (CRI, Number) Beneficiaries of social safety net programs - Female (CRI, 0.00 150.00 350.00 450.00 650.00 800.00 Number) Female beneficiaries complying 0.00 50.00 100.00 300.00 500.00 700.00 with conditionalities (Number) Component 4. Strengthening the multisectoral ECD system and Project management Implementation of the GRM and resolution of grievances within agreed timeframes 0.00 20.00 30.00 50.00 65.00 80.00 (Percentage) (Percentage) IO Table SPACE Page 38 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Number of women who have one or more ANC visits Share of women who have during the first Share of women who have had at least had at least one ante-natal trimester Annual MOHHS MOHHS one ante-natal care visit by a skilled care visit by a skilled Denominator: Number provider during the first trimester (%) provider during the first of women with live trimester (%) births + estimate of women with still births and miscarriages Share of children aged 0-2 years who receive well-child visits as per established Numerator: Number of government guidelines (%). children who regularly Share of children aged 0-2 years who *Well-child visits will be receive well-child visits Annual MOHHS MOHHS receive well-child visits as per established defined as part of the as per guidelines. government guidelines* benefits package Denominator: All development and guidelines children aged 0-2 for delivery of the visits established during the first year of implementation Number of families with Number of families Number of families with children aged 0-4 MOEST/PSS/ MOEST/PSS and children aged 0-4 years Annual with children aged 0-4 years receiving home visits from parent WUTMI WUTMI receiving home visits from years receiving home educators parent educators. Home visits from parent Page 39 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) visits by trained parent educators educators. Numerator: children Share of children aged 3 and aged 3 and 4 years 4 years attending pre- MOEST/PSS/ attending preschool Share of children aged 3 and 4 years Annual MOEST/PSS school. Pre-schools will be EPPSO Denominator: total attending pre-school established and scaled up number of children during the project. aged 3 and 4 years ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of health workers trained in maternal, infant, Number of health workers trained in and young child nutrition Semi- maternal, infant, and young child MOHHS Project data MOHHS promotion (or, trained to annual nutrition promotion (or, trained to deliver deliver a package of a package of essential RMNCH-N services) essential RMNCH-N services disaggregated by gender Number of RMNCH-N Number of RMNCH-N Number of RMNCH-N providers providers undergoing providers undergoing Annual MOHHS MOHHS undergoing regular performance regular performance regular performance monitoring monitoring monitoring (Number) People who have received essential Annual MOHHS Administrative data MOHHS health, nutrition, and population (HNP) services Page 40 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Annual MOHHS Administrative Data MOHHS Number of children immunized Number of women and children who Annual MOHHS Administrative Data MOHHS have received basic nutrition services Number of deliveries attended by Annual MOHHS Administrative Data MOHHS skilled health personnel Every two Number of children aged 3-4 attending Number of children ages 3-4 MOEST/PSS Project data MOEST/PSS months kindergarten attending kindergarten Every two Number of girls aged 3-4 attending Number of girls aged 3-4 MOEST/PSS Project data MOEST/PSS months kindergarten attending kindergarten Number of teaching aides, Number of teaching aides, parent parent educators, coaches Annual MOEST/PSS Project data MOEST/PSS educators, coaches and MOEST/PSS staff and MOEST/PSS staff receiving training under the project receiving training under the project (by gender) Annual MOCIA Project data MOCIA Beneficiaries of social safety net programs Beneficiaries of social safety net Annual MOCIA Project data MOCIA programs - Female Female beneficiaries Female beneficiaries complying with Annual MOCIA Project data MOCIA complying with conditionalities conditionalities Numerator: grievances addressed among those Grievances registered Implementation of the GRM and recorded in the system; related to delivery of project Annual MOHHS Project resolution of grievances within agreed Denominator: benefits that are actually timeframes (Percentage) grievances recorded in addressed (%) the system Page 41 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ME IO Table SPACE Page 42 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ANNEX 1: Implementation Arrangements and Support Plan COUNTRY: Marshall Islands Multisectoral Early Childhood Development Project Project Institutional and Implementation Arrangements 1. The Project implementation requires a multisectoral coordination, involving health, education, internal affairs and finance. Currently there is no agency in RMI with a mandate for early child development. While a number of essential health and nutrition services are available in key hospitals, the same is not true for education services. In both line ministries, these are particularly limited on the OI. Coordination between sectors is minimal and ad hoc. The MOEST/PSS has no mandate for children under five years old and no funding for pre-schools, although they do provide some funding to private pre-schools or through non-governmental organizations in providing support to a limited number of children. MOCIA has the mandate in promoting child rights but does not yet have a clear strategy or plan for implementation, and currently lacks the human resources to do so. The country has no formal social safety nets, with traditional safety nets becoming increasingly inadequate. Design and implementation of the Project will require coordination across the relevant sectors and high-level decision making to ensure Project success. The Project will require considerable capacity building, both of the implementing agencies and frontline human resources, to be effective in achieving the PDO. 2. The MOF, MOHHS, MOEST and MOCIA and their relevant divisions will be the implementing agencies for the core Project activities. The MOHHS is responsible for component 1, the MOEST/PSS is for component 2, the MOCIA for component 3, and the MOF and OCS will be responsible for component 4, as well as processing required documentation for disbursement and replenishment of the program’s DA. A PIU will be established within the OCS and will be responsible for overall coordination, results monitoring, and communicating with the WB for implementation of all Project related activities. The Project will follow the Government’s centralized approach to managing fiduciary, procurement, and safeguards for WB-financed Projects and will engage the CIU, housed in MOF, to provide these functions for the Project. 3. The highest level of the program’s governance is the CC, established by the President to provide high-level leadership and guidance for the RMI’s flagship ECD Program. The CC is chaired by the President and comprises the ministers of the concerned sectoral ministries, with the Chief Secretary serving as secretariat. The CC will be supported by an ECD PSC, chaired by the Chief Secretary, and including Secretaries from the relevant line ministries. The PSC will provide oversight during Project implementation. An ECD Working Group will be formed, chaired by the ECD Program Officer, that will include relevant technical focal points from the implementing line ministries and other relevant agencies (e.g. Economic Policy Planning and Statistics Office, national training institute), staff from the WB-financed PIU, and other stakeholders. The Working Group will facilitate coordination across the RMI’s ECD program and will provide technical inputs to the PSC. 4. Project management will be operating under direct guidance of the ECD SC. As holistic ECD is a new concept in the country and many interventions, systems, and capacities do not yet exist, the PIU will rely heavily on international TA to set up the Project, with the understanding that many of these functions may be readily transferred to line ministry staff in years 3-5 of the Project. The PIU will include (a) ECD Program Officer, internationally recruited; (b) an M&E expert, internationally recruited; (c) a SBCC and Advocacy coordinator, international recruited; and (d) support staff, locally hired. The PIU’s functions will be directed by the OCS. The PIU will be responsible for all core functions of the Project’s implementation, management and the coordination of activities of the implementing agencies. Additionally, each line ministry will have one internationally recruited ECD Coordinator plus one locally recruited ECD Coordinator hired as PIU staff to sit within their respective line ministries of MOHHS, MOEST, MOCIA. The International ECD Coordinator will work closely with the line ministry’s local ECD Coordinator to provide TA to the implementation of the Project’s activities and Page 43 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) build capacity of the sectoral ministries under the assumption that local staff will take over coordinating responsibilities within the line ministries at the later stage of the Project. ECD Coordinators, both international and local, will jointly report to the relevant line ministry Secretary and the ECD Program Officer/Chief Secretary. 5. The various key responsibilities of the PIU will include, among others: (a) Management of various Project activities; (b) Provision of implementation support; (c) Regular coordination with the relevant stakeholders including the WB, MOF, MOHHS, MOEST/PSS, MOCIA, other line ministries, local government and other stakeholders involved in Project implementation and the ECD sector in the RMI; (d) Coordination with CIU on management of funds and operating accounts; (e) Management of consultancy contracts and training; (f) Implementing the ESMF (with support from CIU) (g) Project monitoring, reporting, and evaluation; (h) Coordination with CIU on the financial record keeping, preparation of FM reports, the DAs, and disbursements; (i) Coordination with CIU on reporting including the preparation of Financial Monitoring Reports, Progress Reports, and Procurement Management Reports; and (j) Organizing the various implementation support visits, a mid-term review, and a final review of the Project. 6. The key tasks and responsibilities of the PIU personnel include: (a) ECD Program Officer. He/she will report to the Chief Secretary, and provide management support and assistance to the development, coordination and implementation of a Government-led multisectoral ECD program including providing support to the high level ECD PSC and the Chief Secretary in the day-to-day management, coordination, and monitoring of the ECD Program implementation. This person will be responsible for the ESMF and integrating the requirements into the Program. (b) M&E/impact evaluation specialist. As the Project will test various delivery models in the three areas of health, education and social assistance, it will be important to employ an evaluation strategy to collect rigorous evidence to inform the Government’s decisions for scaling up after the trial. In addition, a single overarching M&E framework for ECD will be established, while UNICEF’s regional M&E framework (that has been agreed at ministerial level across the Pacific) would likely inform this single overarching ECD M&E framework. The M&E and impact evaluation specialist will be leading and providing TA to the Government in carrying out the M&E functions of the Project implementation. (c) SBCC and Advocacy coordinator. This is an important part of the ECD vision of the Government and there will be a need for engagement by many partners to support this. The coordinator will be a member of the ECD PIU and will help lead/coordinate the different activities under a comprehensive SBCC. This person will be responsible for the stakeholder engagement and GRM activities under the ESMF. 7. Key functions and responsibilities of the ECD Coordinator in each line ministry will include, among other things, to: Page 44 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) (a) Provide TA to the ECD team of the line ministry and all concerned stakeholders to ensure Project implementation is delivered in accordance with the POM and the Bank’s operation guidelines, in close collaboration and guidance provided by the ECD PSC through PIU; (b) Assist the implementing agency to prepare annual implementation and budget plan for each Project year in coordination with the ECD Program Officer; (c) Prepare training plans for the staff involved through Project implementation to ensure capacity is built and measured; (d) Prepare the Project progress reports (relevant activities and component) and ensure consistency in quality of information and timeliness of report submission; (e) Assist with the organization of various implementation support visits, including a midterm and final reviews of the Project. (f) Ensure coordination within the line ministry departments and across relevant development partners on sector-specific ECD activities 8. In light of the complexity of Project implementation arrangements, the responsibilities of respective implementing agencies will be outlined in the POM. The POM for the Project will be adopted by the Government by no later than 3 (three) months after the Project effectiveness. It will be updated periodically as elements of the Project evolve, but always with the prior written agreement by the WB. The POM will be used by the PIU and the implementing agencies as a guide to effectively meet their responsibilities under the Project. The objectives of the POM will be to: (a) provide the necessary tools to guide all relevant stakeholders on their key roles and functions; (b) ensure a uniform level of understanding by all stakeholders involved in the interpretation and application of implementation guidelines to achieve process consistency, timeliness, and accuracy; (c) integrate the ESMF into project implementation; and (d) facilitate transparency, equity, and compliance. Page 45 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Figure A1-1: The ECD Project Governance Structure High Level ECD Cabinet Committee Chaired by the President and comprises ministers of MOHHS, MOEST, MOCIA, MOF Secretariat: Chief Secretary Chief Secretary Office ECD Program Steering Committee (PSC) Chaired by the Chief Secretary, Members: Secretaries of MOHHS, MOEST, MOCIA, MOF, Ministry of Justice, representatives from Ebeye local government Marshall Islands Council of NGOs Secretariat: ECD Program Officer ECD Working Group Chaired by ECD Program Officer and includes line ministry focal points, ECD Program Officer, UNICEF ECD Coordinator, PIU Staff, relevant stakeholders Central Project Implementing Unit (PIU) Implementing Comprises: ECD Program Officer; M&E Coordinator, SBCC Coordinators Unit (CIU) MOHHS MOEST/PSS MOCIA 1 Intl TA: ECD Coordinator 1 Intl TA: ECD Coordinator 1 Intl TA: ECD Coordinator 1 MOHHS ECD Coordinator 1 PSS ECD Coordinator 1 MOCIA ECD Coordinator Divisions and staff concerned Divisions and staff concerned Divisions and staff concerned Stakeholders implementing ECD services financed by the program 9. Cabinet Committee on ECD. The CC was established by Cabinet on June 21, 2018 via Cabinet Minute 130(2018). The committee is to provide high-level strategic leadership and guidance for the RMI’s flagship ECD Program and broader efforts in this area. The committee will work with and receive regular reports and updates from an ECD PSC. The committee consists of five members: 1) the President; 2) Minister of Health and Human Services; 3) Minister of Education, Sports and Training; 4) Minister of Culture and Internal Affairs; and 5) Minister of Finance. 10. ECD Program Steering Committee. ECD PSC will provide oversight, coordination, and implementation support for the RMI’s flagship ECD Program and other programs and efforts in this area. The PSC shall meet quarterly, of which 1-2 meetings will be held in Ebeye. The PSC will work closely with all development partners supporting ECD related efforts in the RMI. The committee shall provide regular reports and updates to the CC on ECD. The PSC shall consist of heads of the following offices and organizations: 1) Office of the Chief Secretary (Committee Chair); 2) Ministry of Health and Human Services; 3) Ministry of Education, Sports and Training; 4) Ministry of Culture and Internal Affairs; 5) Ministry of Finance; 6) Ministry of Justice, Immigration, and Labor; 7) Representatives of Ebeye local government; and Page 46 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 8) Marshall Islands Council of Non-Governmental Organizations. Financial Management 11. An FM assessment of the CIU in MOF, which will be responsible for fiduciary aspects, was carried out in accordance with the “Principles Based Financial Management Practice Manual” effective March 1, 2010. Under the Bank’s Directive: Investment Project Financing (Directive), the borrower and implementing agencies are required to maintain financial management systems, including accounting, financial reporting, and auditing systems, adequate to ensure accurate and timely information regarding the Project resources and expenditures. Overall, the assessment found that the FM arrangements satisfy the requirements as stipulated in the Directive subject to the implementation of agreed actions and mitigating measures. The CIU is responsible for the FM arrangements for the whole Project. The CIU is a newly-formed unit and currently has limited capacity. A Finance Manager employed in 2017 is solely responsible for the FM requirements for the current portfolio. With the current staff levels, there is a risk of over-extending current project management resources in MOF, which could be a constraint to the implementation of this Project absent additional Project support. A dedicated FM Officer for this Project is recommended to be recruited subject to an assessment of the scope of the work required given the complexity of the Project especially in the administration of sub-component 3.2 on CCTs. The POM will include a section on budgeting, disbursement, and financial management arrangements. The sharing of services with other WB projects will require processes to ensure that expenditures are properly recorded and documented, and associated funds flows closely monitored. Training on the FM requirements of the Project will be conducted and monitoring of compliance with FM processes will be a regular part of the implementation support visits. 12. FM Implementation Arrangements. The CIU in MOF maintains the financial accounts and provides FM support to WB projects and hence will be responsible for the fiduciary aspects of this Project. CIU currently has a Finance Manager. It is proposed that an additional FM Officer dedicated for this Project be recruited to ensure that the FM arrangements satisfy the requirements as stipulated in WB Directive: Investment Project Financing. The Project FM Officer will also coordinate the financial management requirements of the Project with the ECD PIU. The FM risk of the Project is assessed as Substantial primarily because of the risk of over-extending MOF’s current project management resources, which could be a constraint for the implementation of this Project absent additional Project support. In addition, multiple line ministries (MOHHS, MOEST, MOCIA) implementing their respective components further contributes to the complexity of the FM arrangements for the Project. 13. Budgeting Arrangements. The RMI has a Budget Coordinating Committee which develops, formulates, and coordinates the Government budget process. This committee primarily consists of the MOF staff who have strong skills in budget preparation and monitoring of the budget. Project funds will be included in the estimates and in-year reporting subject to the timely notification to the Government. The budget section of the MOF is responsible for the monitoring of the Government budget throughout the year and will be requested to work closely with CIU fiduciary staff to assist in the budget preparation and monitoring of this Project. The Government accounting system has the capacity to compare actual costs to budget, which will assist in the monitoring of the budget. Budgeting will be on an activity basis summarized by component and should be reviewed at least every six months by both the budget section of the MOF and the Project team. 14. Accounting Arrangements. The 4Gov system has a chart of accounts, and transactions or line items can be further classified by cost center, organization (department/division), and geography if required. This system can maintain accounting records that meet the Bank’s reporting requirements for this Project. A new chart of accounts will be developed for the new financial management information system (FMIS) and the Project accounts will be incorporated in the new system. Separate cost centers will be opened to account for transactions under the respective components to be implemented by line ministries (MOHHS, MOEST, MOCIA), with all related payments centralized in MOF. The new FMIS will include the capability to account for WB financed projects and it is anticipated that there will be a transition period during which both the existing 4Gov system and the new FMIS will be running in parallel, after which the 4Gov Page 47 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) system will be decommissioned. There is a recommendation for the provision of a Project FM Officer if required and FM capacity will be required to be adaptable to changing FM systems and running parallel systems. 15. Internal Controls. The Government of the RMI uses a Standard Operations Procedure Manual, which outlines the internal controls and procedures. However, compliance within agencies has often been poor. This risk should be mitigated by ensuring that the Project FM Officer is aware of the Standard Operations Procedure Manual requirements, and that compliance to the manual is included in the TORs of the position. To enhance the controls, all Project Purchase Orders will be approved by the Secretary of Finance prior to release. The Internal Audit unit (currently staffed with an Internal Auditor and an Internal Audit Head recently hired) within MOF may be able to provide additional oversight. A POM will include a section on budgeting, disbursement, and financial management arrangements that will reference relevant Government legislation, procedures and the Standard Operations Procedure Manual and will outline in more detail FM arrangements specific to the Project. 16. Flow of Funds. Funds will flow from the WB directly into a DA. Initially this will be through the PPA which, on refinancing, will become the Project DA. Expenditures from the PPA will be tracked through the Government accounting system and paid from the treasury account. Prior to completing a replenishment Withdrawal Application, the equivalent funds expended from the treasury account will be transferred from the DA into the treasury account, and the DA will be replenished by that amount. Adequate documentation is required to be maintained to ensure easy reconciliation of payments made from the treasury account to payments authorized by the Project. For larger Project payments, the direct payment disbursement method can be chosen for use by the MOF and the Withdrawal Application enables funds to flow directly from the WB to the supplier. Where direct payments are used as the disbursement method, the transactions must be incorporated into the Project accounts. To facilitate the tracking of multiple Projects, and the associated funds management aspects, it is proposed that the ‘statement of expenditure’ method be used when documenting Project expenditures and replenishing the DA. 17. Financial Reporting. Financial reporting will be fully integrated into the Government accounting system. The Project will be allocated a cost center, and sub-accounts will be created to reflect the specific activities. Reports will initially be generated from the 4Gov accounting system and will ultimately be generated by the new FMIS. The financial reports will include an analysis of actual expenditure for the current period, year to date, and for the cumulative to date, plus outstanding commitments, compared against total Project budget. The Project will be required to prepare semi- annual (semester) Interim Financial Reports in a format agreed with the Bank. The Interim Financial Reports will be prepared by the Project Finance Officer in consultation with MOF and will be required to be submitted not later than 45 days after the end of the reporting period. There remains a risk of limited financial information provided in the Interim Financial Reports due to difficulties of staff extracting information from 4Gov. This will be overcome during the life of the Project which will address reporting issues in the specifications for the new FMIS and provide training to MOF staff. 18. Audit. The audit of Project funds will be incorporated in the National Accounts and hence will be disclosed as a note to the accounts of the National Accounts, with submission due nine months after the end of the fiscal year. There is a risk that, through an oversight, the Project information is not included in a note to the accounts. To reduce the risk, each year the WB will formally write to MOF advising them of the projects that need to be included in the disclosed World Bank project note. Currently, the audit of the National Accounts is sub-contracted by the Public Auditor to a private contractor. The MOF, the Public Auditor, and the WB will agree on the information required to be disclosed. The National Accounts will be published on the Office of the Auditor General’s web site. Disbursements 19. Disbursements under the Project may utilize any of the following methods: (a) advances into and replenishment of the DA; (b) direct payment; (c) reimbursement; and (d) Special Commitment. Direct payments will be used solely for large contracts. Page 48 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 20. Project funds will be disbursed directly into a DA in a commercial bank acceptable to the WB. The DA, which will be held in US dollars, will be operated on an advance basis and the initial advance will be made through the completion and submission of a Withdrawal Application. Subsequent replenishments will be made through the submission of Withdrawal Applications, along with details on the use of funds previously advanced, based on Statements of Expenditures and the bank reconciliation of the DA. 21. Table A1-1, Financing Agreement Disbursement Categories and Amounts, shows the categories of expenditure and eligible amounts for financing; these can also to be found in the Financing Agreement. In the event of a discrepancy, the table in the Financing Agreement takes precedence over the table shown below. Table A1-1: Financing Agreement Disbursement Categories and Amounts (IDA Financing) Amount of the Category Financing Allocated Percentage of Expenditures to be US$ Financed (inclusive of Taxes) (1) Goods, works, non-consulting services, 10,575,000 100% consulting services, operating costs, and training and workshops for the Project (2) Cash Transfers under Part 3.2 of the 1,500,000 100% Project (3) Refund of Preparation Advance 925,000 Amount payable pursuant to Section 2.07(a) of the General Conditions Total 13,000,000 22. As noted in the Financing Agreement, no disbursement can take place under Category (2) unless and until the Association has received evidence to its satisfaction that: (i) the following aspects of the Conditional Cash Transfer Program have been developed: (A) a management information system for the enrolment, compliance verification and payments; (B) a grievance redress mechanism; and (C) guidelines for a monitoring and evaluation framework, all as satisfactory to the International Development Association; (ii) the Memorandum of Understanding has been finalized and signed in accordance with Section I.D of Schedule 2 to the Financing Agreement; and (iii) the Project Operations Manual has been prepared and adopted in accordance with Section I.B of Schedule 2 to the Financial Agreement. Procurement 23. Applicable procurement procedures for contracts financed in whole or in part by the IDA Grant, procurement would be carried out in accordance with the WB’s “Procurement Regulations for IPF Borrowers: Procurement in Investment Project Financing” dated July 2016, revised November 2017 and August 2018, and the provisions stipulated in the Financing Agreement. Under the proposed Project, the WB’s planning and tracking system, STEP, will be used to prepare, clear, and update Procurement Plans and conduct all procurement transactions for the Project. Accordingly, all the procurement activities under the proposed Project will be entered into, tracked, and monitored online through the system. 24. Procurement Capacity and Risk Assessment for the Project was conducted during the procurement mission between August 16-17, 2018, and the procurement risk is assessed as High. There are multiple implementing agencies Page 49 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) for the Project, with the MOEST/PSS and MOHHS having varying degrees of experiences including procurement under foreign-assisted projects, while MOCIA has undertaken mostly smaller procurements. However, all three sectoral agencies are new to the WB processes, including its Procurement Regulations and procedures. 25. In order to mitigate the above identified risks and strengthen the procurement capacity of the Project, the following measures have been established and agreed to be implemented: (a) procurement specialist in the CIU in MOF to provide TA and support to the Project; (b) the Program Officer and the respective sector Program Coordinators TORs will include procurement related functions, among others; (c) Project staff will be continuously provided with relevant procurement training and implementation support by the World Bank; (d) the STEP system will be used to prepare, clear and update Procurement Plans and conduct all procurement transactions for the proposed Project (accordingly, all the procurement activities under the proposed Project will be entered into, tracked and monitored online through the system); and (e) a POM with a Procurement Module will be prepared to guide the Project in carrying out procurement. 26. Procurement strategy. Based on the Project requirements, operational context, economic aspects, technical solutions and market analysis, a Project Procurement Strategy Document (PPSD) has been developed for the Project. The PPSD identified the major and critical types of activities such as (i) individual consultants (ECD Program Officer and Project Coordinators for the three sectoral ministries) which will be advertised in as many channels as possible to attract adequate number of qualified consultants; (ii) consulting firms for the various requirements (monitoring, RMNCH-N package, HR Strengthening and others) will be engaged through Consultants Qualification Based Selection through open competition and direct invitation of known firms to facilitate selection and contracting process. A number of individual requirements have been lumped to form a package contract to facilitate and make procurement more efficient and economical. 27. Procurement Plan. Based on the PPSD, the initial Procurement Plan for the first 18 months of the Project was prepared by the government and agreed on by the WB at negotiations. The Procurement Plan will be updated at least annually by the PIU, with support from the procurement specialist in the CIU and PIU staff, and agreed with the World Bank to (a) reflect Project implementation updates; (b) accommodate changes that should be made; and (c) add new packages as needed for the Project. All Procurement Plans, their updates, or modifications shall be subject to the World Bank’s prior review and no-objection through STEP. Details for the procurement arrangements will be provided in the POM. The Project Procurement Plan identifies the risk for each activity, and prior review thresholds for these activities is set based on the performance and risk rating; contracts not subject to prior review will be subject to post review. The World Bank will carry out procurement post reviews annually with an initial sampling rate of 20 percent, which will be adjusted periodically during Project implementation based on the performance of the Project. 28. Procurement methods. Table A1-2 and the subsequent paragraphs describe the various procurement methods to be used for activities financed by the proposed IDA Grant. Table A1-2: Procurement Methods Type of Procurement Selection Methods 1. Works RFQ 2. Goods RFQ, RFB 3. Consulting Services - Firms QCBS, QBS, FBS, CQS and CDS 4. Consulting Services - Individuals INDV (Open, Limited, and Direct Selection) Note: RFQ = Request for Quotation; RFB = Request for Bids; QCBS = Quality- and Cost-Based Selection; QBS = Quality-Based Selection; FBS = Fixed Budget Selection; CQS = Selection Based on the Consultants’ Qualifications; CDS = Direct Selection; INDV = Individual Consultant Selection. 29. The Procurement Plan for the first two years is in Table 1.3 below. Page 50 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Table A1.3: Procurement Plan (April 2019 to June 2021) Project Estimated Bank Reference Procurement Procurement Planned Start Planned End Component Description Amount Financed No. Category Method Date Date # (US$) % ECD Program Officer 4.3 CS INDV 650,000 100 January-2019 April-2021 (International) ECD Coordinator - Health 1.1 CS INDV 440,000 100 April-2019 April-2021 (International) ECD Coordinator - Health 1.1 CS INDV 60,000 100 April-2019 April-2021 (National) ECD Coordinator - Education 2.1 CS INDV 440,000 100 April-2019 April-2021 (International) ECD Coordinator - Education 2.1 CS INDV 60,000 100 April-2019 April-2021 (National) ECD Coordinator - CCT 3.1 CS INDV 440,000 100 April-2019 April-2021 (International) ECD Coordinator - CCT 3.1 CS INDV 60,000 100 April-2019 April-2021 (National) ECD Financial Management 4.3 CS INDV 60,000 April-2019 April-2021 Specialist RMNCH-N package and 1.1 CS CQS 500,000 100 May-2019 May-2021 delivery Human resources 1.1 CS CQS 350,000 100 May-2019 May-2021 strengthening Specialist service delivery September- 1.2 CS INDV 200,000 100 June-2021 contractors 2019 Equipment, commodities and 1.2 GO RFQ 200,000 100 July-2019 June-2021 supplies 1.2 Minor civil works CW RFQ 110,000 100 July-2019 July-2021 TA -review and development 2.1 CS DIR 120,000 100 April-2019 March-2020 of training materials Page 51 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) TA for teacher training - batch 2.1 CS DIR 60,000 100 June-2019 August-2019 1 TA for teacher training - batch 2.1 CS DIR 75,000 100 January-2020 August-2021 2 2.2 Classroom furniture Goods RFQ 40,000 100 April-2019 August-2019 2.2 Educational toys Goods RFQ 25,000 100 April-2019 August-2019 CCT - Assessments and 3.1 CS CQS 200,000 100 April-2019 April-2021 training 3.1 IT Hardware for CCT program GO RFQ 30,000 100 June-2019 December-2019 3.1 Rehabilitation of IT room CW RFQ 5,000 100 July-2019 October-2019 Monitoring, evaluation and 4.1 CS CQS 200,000 100 June-2019 June-2021 learning 4.1 M&E Coordinator CS CQS 125,000 June-2019 June-2021 4.1 Surveys and surveillance NCS RFQ 100,000 100 June-2019 June-2021 ECD Awareness and SBCC 4.2 CS CQS 100,000 100 January-2019 June-2021 Campaign 4.2 SBCC Coordinator CS CQS 125,000 June-2019 June-2021 4.3 Equipment and supplies GO RFQ 40,000 100 April-2019 December-2019 Page 52 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Environmental and Social (including Safeguards) 30. Safeguards will be integrated into project implementation through the SBCC and outreach activities, GRM (including feedback mechanisms) and M&E. Therefore, the implementation of the ESMF will be the responsibility of the ECD PIU. The Safeguards Advisor in the CIU will provide ESMF training for the ECD PIU and provide ad hoc support for ESMF implementation such as screening for physical investments and TA, preparing and supervising building renovations and waste management. M&E 31. Progress toward the PDO will be monitored through reporting on the PDO-level and intermediate level results indicators. A Results Framework with Project-specific indicators and actionable monitoring arrangements has been developed jointly with the MOHHS, MOEST/PSS, MOCIA and other stakeholders. This will be used for monitoring of implementation progress and results of Project implementation. Overall monitoring and coordination of Project activities will be performed by the implementing agencies under guidance of the PIU and ECD Program Officer. 32. The Intermediate Results Indicators will be monitored through administrative data provided to the PIU M&E Specialist by the line ministries MOHHS, MOEST/PSS and MOCIA, the training providers being covered under the Project, and all other stakeholders involved in the Project implementation such as local authorities, non-governmental organizations, hospitals, schools, etc. The M&E Specialist will be responsible for collecting this administrative data from the relevant Government ministries and other Project stakeholders on a quarterly basis. Role of Partners 33. Other development partners also support ECD in the RMI. The WB has consulted extensively with the two key development partners operating in ECD, UNICEF and the ADB. UNICEF carried out the Integrated Child Health and Nutrition Survey in 2017, which provided the data and analytical basis for the preparation of this project. UNICEF is also carrying out formative research on health and nutrition behaviors and practices currently, and is expected to provide support on behavior change communication and strategies going forward. The ADB is financing a new program on primary education and may support immunization systems strengthening in the future. Strategy and approach for implementation support 34. The strategy for implementation support has been developed based on the nature of the Project and its risk profile. The aim is to make implementation support to the client flexible and efficient. The overall risk rating for this Project is Substantial, primarily due to the limited technical capacity of the implementing agencies and limited experience in implementing WB projects. This is also a new engagement for the WB, both in the sector and in the country. Lack of prior engagement and the logistical challenges of travel to the country for face-to-face dialogue impact the frequency and cost of implementation support visits. 35. The Implementation Support Plan for this Project will comprise regular dialogue with the MOHHS, MOEST/PSS, MOF and MOCIA; systematic joint reviews of program implementation; and regular oversight and support for Project fiduciary activities with emphasis to be placed on the risks surrounding institutional capacity identified in the Systematic Operations Risk-Rating Tool, which are typical across the public sectors in most small island states. Regular dialogue and ongoing implementation support will enable the early identification of problems and permit the provision of timely TA to correct any potential issues that arise. 36. The World Bank will provide ongoing support by coordinating with the client and among WB staff who will provide implementation support on technical, fiduciary (FM and procurement), and safeguards aspects. The WB will conduct field supervision visits at least twice a year, and, in collaboration with Government counterparts, will monitor progress against the indicators in the Results Framework. The WB will flexibly conduct additional technical visits as required. The WB will also monitor risks and update the risk assessment and risk management measures as needed. Page 53 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 37. In relation to the fiduciary aspects of the operation, the WB will provide support in the areas of procurement and FM, as required. This will include (a) providing training to the respective staff; (b) assisting with the technical specifications for TORs; (c) examining procurement documents and providing feedback to the Procurement Specialist at the CIU; (d) monitoring progress that has been made against the detailed Procurement Plan; (e) reviewing the FM system and planned arrangements; (f) assisting with accounting, reporting, and internal controls; and (g) reviewing submitted reports and providing feedback to the Financial Management Specialist at the CIU. 38. A midterm review will be conducted in December 2022 or such other date as agreed with the Government, to take stock of performance under the Project. Based on the assessment of progress at the mid-point of the Project, recommendations for improvements/changes to the Project will be considered by the Government and the WB. 39. As a part of the joint reviews between the Government and the Bank, the lessons learned from implementing the Project POM will be sought. These will be incorporated into future revisions of the POM if necessary and further training will be offered for PIU staff and other relevant stakeholders where necessary. Implementation Support Plan and Resources Requirements 40. The lack of institutional capacity within the line ministries for the implementation of WB projects means that this operation will require relatively dedicated implementation support. This is expected to be relatively intensive during the first 12 months of the operation as the PIU and line ministries become accustomed to the requirements of WB guidelines and procedures. As such, three implementation support visits will take place during the initial year of implementation, after which they will be reduced to two visits in subsequent years of the Project implementation. These periodic support visits will be complemented by regular correspondence, audio and video connections with relevant counterparts. Time Focus Skills Needed Resource Estimate First 12 months Implementation support coordination Task Team Leaders 8 (staff Overall technical support Health Specialist weeks/year) 5 Overall technical support Education Specialist 5 Overall technical support Social Protection Specialist 5 IT Assessment and MIS development support IT/MIS Specialist 3 Overall operational support Operations Officer 4 FM FM Specialist 2 Procurement Procurement Specialist 2 Safeguards Safeguards Specialist(s) 1 12–48 months Implementation support coordination Task Team Leaders 6 Overall technical support Health Specialist 3 Overall technical support Education Specialist 3 Overall technical support Social Protection Specialist 3 IT Assessment and MIS development support IT/MIS Specialist 2 Overall operational support Operations Officer 2 FM FM Specialist 1 Procurement Procurement Specialist 1 Page 54 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Time Focus Skills Needed Resource Estimate Safeguards Safeguards Specialist(s) 1 (staff weeks/year) Page 55 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ANNEX 2: Project Description COUNTRY: Marshall Islands Multisectoral Early Childhood Development Project 1. This Project will support the Government of RMI in establishing a sustainable system to promote ECD. It will do so by: (i) supporting the government to expand public sector delivery of essential ECD services; (ii) providing targeted support to increase coverage and intervention intensity of these services for vulnerable early years families; and (iii) strengthening the public sector systems necessary to institutionalize and sustain a multisectoral ECD program. The Project consists of four components: - Component 1: Improve coverage of essential RMNCH-N services; - Component 2: Improve coverage of stimulation and early learning activities; - Component 3: Social assistance for early years’ families; and - Component 4: Strengthening the multisectoral ECD System and Project management Component 1: Improve coverage of essential RMNCH-N services (Total US$4.23 million, of which IDA: US$3.66 million, Government: US$0.57 million) 2. Component 1 aims to improve the availability and coverage of an evidence-based package of essential RMNCH- N and stimulation services for the first 1,000 days (pregnant and lactating women and children up to age 2). Adolescent girls, women of reproductive age and children aged 2-5 years will be secondary target groups, with interventions for these populations incorporated in an opportunistic manner and/or in later stages of Project implementation. The component seeks to both strengthen the package of services provided and alleviate supply- and demand- side barriers to the use of this package of services. The first two years of the Project will focus on alleviating key pressure points to ensure adequate coverage of a revised and evidence-based package of RMNCH-N services in the Majuro/Ebeye Hospitals. Project financing will focus on strengthening hospital and clinic-based service delivery in Majuro and Ebeye and filling short-term gaps in supply-side readiness in OI clinics. This immediate term measure is considered vital for preventing further deterioration of key health and nutrition outcomes. The component will also support a suite of TA activities to identify strategic shifts in service delivery in order to inform further scale-up beyond the initial phase. 3. The component has two sub-components; one aimed at strengthening stewardship and management of health administration and the other at directly strengthening service delivery. Each sub-component will have four dimensions: (a) RMNCH-N service package; (b) human resources; (c) equipment and supplies; and (d) data and information (see Table A2.1). Table A2.1: Activities supported in component 1 Dimension Sub-component 1.1 Sub-component 1.2 RMNCH-N Service Package • TA to define essential service • Support to MOHHS in the delivery of revised package and delivery options RMNCH-N package • Supply-side readiness assessment • Health Financing Systems Assessment Human • Human Resource Needs Assessment • Contract staff to optimize number and skill mix Resources • Development of capacity building • Delivery of comprehensive training and capacity and training packages building Equipment and Supplies • TA on forecasting, purchasing, • Small equipment and supplies to ensure procurement, and commodity readiness to deliver RMNCH-N package management Page 56 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Data and Information • Development/revision of databases • Minor upgrading to IT hardware and software to to meet M&E needs associated with improve record keeping and decision making revised RMNCH-N package 4. Implementation of SBCC activities will be financed under component 1 and other components (described in Component 4). While component 1 will support MOHHS in the delivery of early years-focused SBCC activities in combination with other RMNCH-N interventions, a comprehensive, cross-sectoral SBCC strategy and campaign will be developed under component 4. Sub-component 1.1 will support the development and roll-out of training, capacity building, and coaching packages required for MOHHS to effectively deliver SBCC, whereas sub-component 1.2 will finance the production of materials, roll-out and delivery of the campaign through MOHHS channels. 5. Sub-component 1.1: Strengthening MOHHS management and stewardship capacity to deliver essential RMNCH- N services. The objective of this sub-component is to strengthen the management and stewardship capacity of MOHHS to scale up access to a package of essential RMNCH-N services. Activities/inputs to be financed include: • Essential RMNCH-N Service Package: The Project will finance a suite of TA activities to define an essential RMNCH-N package, assess supply-side readiness to deliver the package and recommend strategic shifts in service delivery needed to improve coverage and utilization. While many RMNCH-N interventions are underway, there is a need for MOHHS define and deliver a basic essential package of services, strengthening areas such as: maternal nutrition counselling during ANC; infant and young child feeding promotion; routine monitoring and promotion of optimal child growth and development; identification of disability and developmental delay, birth registration, etc. The component will support an assessment to define the essential RMNCH-N package and an expanded package of activities as well as accompanying operational guidelines for the essential package. A supply-side readiness assessment, will be undertaken to identify frontline needs and gaps. A service delivery study will be undertaken and complemented by a Health Financing Systems Assessment to develop recommendations for sustainable, cost-effective delivery models and modalities in Majuro/Ebeye and the OI. • Human Resources: The Project will finance: a human resources mapping and needs assessment to develop a HR strategic plan focusing on the delivery of the essential RMNCH-N package; TA to develop a performance management system; the development of training and coaching packages as identified in the needs assessment. Two ECD Coordinators (national and international) will be placed within the MOHHS, who will not only be responsible for managing activities under the Ministry’s mandates (as discussed under component 4), but in doing so will provide specific guidance to staff in the ministry and other implementing agencies to build capacity to work on their mandate in the future. It is expected that the national ECD coordinator will be absorbed into the MOHHS payroll during the life of the project (approximately year 4). • Equipment, commodities, and supplies: The Project will finance TA on forecasting, purchasing, procurement, and commodity management, as needed. • Data and information: The Project will undertake a rapid assessment of the data needs of the MCH and RH programs to monitor RMNCH-N service utilization and outcomes as well as the existing HMIS. The assessment will be used to identify gaps in the existing HMIS that already benefit from support from Taiwan, China. 6. Sub-component 1.2: Enhancing delivery of essential RMNCH-N services. The objective of this sub-component is to scale up access to and coverage of a package of essential RMNCH-N services. This sub-component will support the following: • Essential RMNCH-N Service Package: The Project will finance support MOHHS in delivering the newly defined package (See sub-component 1.1). This includes: the production of materials, job aides, etc.; routine operational costs of service delivery, including SBCC activities, in accordance with operational guidelines. In the first 12-24 months of the Project, the focus will be on enhancing RMNCH-N delivery in Majuro/Ebeye Page 57 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Hospitals and Laura Clinic. Special attention will be paid to enhancing the availability of evidence-based nutrition specific interventions, which have fallen through the cracks in primary health care. Service delivery will be scaled up to other areas based on the service delivery TA produced during Year 1 (see also sub- component 1.1). • Human Resources: The Project will finance contracted service delivery providers (e.g. doctors, nurses, midwives) to support MOHHS to achieve a more optimal number, distribution, skills/skills mix, and performance of health care professionals required to effectively deliver the RMNCH-N service package. This includes: (a) surge support to Majuro/Ebeye Hospitals to fill critical human resource gaps for RMNCH-N provision; (b) additional health providers to complement and assist the Health Assistants in the OI Dispensaries in delivering RMNCH-N services; (c) a third-party provider to deliver training and coaching to boost provider skills and adherence to guidelines; and (d) design and roll-out of a transparent performance management system, including the associated management, supervision, and mentoring costs. Direct hire or contracting arrangements identified as appropriate by the service delivery TA will be used for (a) and (b). It is expected that contract providers will be absorbed into the MOHHS payroll during the life of the project. Therefore, the number and type of additional contract staff will be included in the annual work plan and budget, and jointly agreed between the Government of RMI and the WB. Counterpart financing is one option that may be considered. • Equipment, commodities and supplies: The Project will finance the procurement of small equipment (including anthropometric measurement equipment), materials, pharmaceuticals/commodities, in order to meet standards of readiness to deliver the basic essential RMNCH-N package. In the first phase, procurement will be limited to filling equipment, commodity, and supplies requirements for the Majuro/Ebeye Hospitals, Laura Clinic, and OI Dispensaries. Additional equipment/commodity/supply requirements may be identified in in the strategic mapping and the component can finance costs of upgrading OI dispensaries and/or equipping zone nurses, health outreach workers, mobile clinics, etc. to deliver the RMNCH-N service package. Investments in the immunization cold chain will be complementary to those financed under the Asian Development Bank’s regional immunization TA. • Data and Information Technology: The Project will finance gaps in the IT system infrastructure (hardware, software, and training) to monitor RMNCH-N patient records and service utilization, manage stock, and assess performance. Enhancing the availability, quality, and use of data for decision-making will be necessary in order to translate the supply- and demand-side investments to improved health and nutrition outcomes. With support from Taiwan, China, efforts are underway to upgrade and modernize the HMIS. Development of innovative IT solutions to strengthen community outreach and service delivery may be considered at the midterm review. The Project will further support the development of a database and digital dashboards to make the information for decision-making readily available. Component 2: Improve coverage of stimulation and early learning activities (Total US$ 3.79 million, of which IDA: US$3.16 million, Government: US$0.63 million) 7. Component 2 aims to improve children’s cognitive and socio-emotional development and facilitate children’s readiness for on-time transition to primary school through expanding access to stimulation and early learning services. In the absence of a national program for children under five years old, in parallel with the interventions provided under component 1, component 2 will support to increase access to quality services of early stimulation and learning to more children under five years old. The component will strengthen existing service platforms aimed at directly improving delivery of early learning and stimulation services to children ages 0 to 4 years, focusing on improving cognitive, social emotional and other skills needed for school readiness and preparedness for life of children, and to strengthen the MOEST’s stewardship and management capacity in monitoring implementation and quality assurance of services. This component will be managed by MOEST in coordination with the PIU and CIU. Page 58 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 8. Sub-component 2.1: Strengthening MOEST management and stewardship of ECD services. The capacity of MOEST to manage and steward the implementation of ECD interventions will be strengthened to carry out the activities under sub-component 2.2. This will involve strengthening the institutional capacity and regulatory framework of ECD programs in RMI, including planning, budgeting and allocation of resources and enhancing the availability and capacity of human resources to support implementation, service delivery and monitoring at different levels of education system. During the first year of the Project implementation, TA will support MOEST to conduct further assessment in order to develop a detailed, actionable and practical implementation roadmap of all activities under component 2 for the whole project cycle, including staff, facilities, and resource capacity, timing, implementation arrangements monitoring and supervision, etc. The project will also support the development of coaching materials and other inputs needed for the SBCC program to be delivered by MOEST. 9. TA will be provided under the Project to work with the relevant component 2 agencies to assess the existing capacities and regulatory frameworks related to oversight and delivery of ECD services, and revise, strengthen, and develop as needed for institutionalization of ECD services during the later years of Project implementation. Two ECD Coordinators (national and international) will be placed within the MOEST, who will not only be responsible for managing activities under the Ministry’s mandates (as discussed under component 4), but in doing so will provide specific guidance to staff in the ministry and other implementing agencies to build capacity to work on their mandate in the future. It is expected that the national ECD coordinator will be absorbed into the MOEST payroll during the life of the project (approximately year 4). 10. Sub-component 2.2: Enhancing delivery of stimulation and early learning activities. Activities under this sub- component will focus on strengthening existing platforms of ECD services for caregivers and children under five years old. Two on-going interventions with supporting global evidence of positive impacts on outcomes for children will be implemented and scaled up: the delivery of home visits and the creation of public preschools to cater to children ages 3- 4 years old. For each intervention, the Project will finance: (i) TA to develop curricula, training programs and other materials to strengthen quality of service delivery and ensure context appropriateness following a review of existing materials; (ii) the recruitment where needed and training of dedicated personnel providing the services, including TA for training and coaching, travel, accommodation and other associated costs; (iii) procurement, printing and distribution to end users of necessary resources; (iv) procurement of additional facilities and equipment as required; (v) administrating the program at the central level and in the Outer Islands; (vi) grants to run the home visit program; (vii) expenses required for implementation; and (viii) delivery of SBCC activities through MOEST. 11. Sub-component 2.2 will implement a two pronged-approaches; during the earlier years of Project implementation, the project will start up with existing resources available to expand the home visit program in Majuro and Ebeye, and set up four preschools in Majuro, while putting in place the resources needed to strengthen the quality of the two interventions. This includes recruiting TA and contracted service providers, reviewing and developing resources and training programs, identifying and equipping venues for preschools, identifying eligible families, training existing and new personnel working on implementation of the two interventions, and developing a suite of monitoring tools. Additional geographic areas could be included under sub-component 2.2 if resources become available and agreed between the Government of RMI and the WB. Home Visits 12. Overview. Under the Project, an existing MOEST-financed home visit program, providing caregiver education on stimulation and early learning activities with children under 5 years, will be expanded to increase the dosage, coverage and quality of the intervention. During home visits, trained parent educators engage with caregivers and children in a variety of activities that can impact on various aspects of childhood development, including fine motor skills, hand eye coordination, language skills, social skills such as co-operation and taking turns, as well as problem solving skills. Parent educators also provide information to caregivers on good caregiving practices, including health, nutrition, hygiene and stimulation. Page 59 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) 13. Targeting. Currently, the MOEST-financed program provides home visits to a limited number of families in Majuro for one hour a month only due to funding constraints. This program will be strengthened and expanded to reach children from 0-4 years of the most vulnerable families in Majuro and Ebeye as identified through the targeting and family identification carried out under component 3. 14. Implementation. Under this Project, the home visits program, which may include, but not be limited to, the Ajri In Ibwinini Program implemented by Women United Together Marshall Islands (WUTMI)1, will be strengthened and expanded in Majuro and gradually expanded to Ebeye. Home visits will be doubled from one to two monthly visits per family, and number of targeting families will be increased to ensure the most vulnerable families in all communities in Majuro and Ebeye have access to the service. The Project will support provision of required resources and training for implementation, and families will be provided educational toys and other resources that they can share with their children. Each visit lasts at least one hour, with participation of children aged 0-4 years and their caregiver(s). The sessions will follow the guides and materials developed and adapted by the Project. The Project will apply the same stipend currently used for home visits and cover travel costs for parent educators if they are visiting families in other communities. Delivery of home visits will be carried out in accordance with procedures to be detailed in the POM. 15. In addition to monthly home visits to the targeted families, parent educators will be responsible for organizing and facilitating monthly community playgroups. The playgroups will be open for all families in the community with children under five, one session a month on a day the community selects. These monthly community playgroups will be a venue for children to engage in a variety of different play activities with their peers and caregivers, co-organized by the parent educators and attending caregivers. This is a platform for social and community connectedness through the development of informal social networks and by linking families to local community resources and services for parenting education. 16. The current Home visits program will begin expanding in Majuro in the first year of project implementation, and be expanded further across Majuro and to Ebeye in stages during the life of the project. During the first year, the Project will identify eligible families (under component 3), and MOEST/PSS will prepare a detailed implementation plan for expansion with assistance of TA. Public Pre-schools 17. Overview. The Government has no mandate for preschool for children under five, and there is no public funding for schooling this age group. As a result, there are only about five percent of 3-4-year-old children currently enrolled in the few existing private preschools (or Pre-K’s). The Project, therefore, will support the creation of public preschools to cater to 3-4-year-old children, aimed at better preparing them to be ready for formal schooling by the time they reach Grade 1. 18. Targeting. The Project’s ultimate objective is to support the government in ensuring all children ages 3-4 years old have access to quality ECE services in RMI. However, given the limited capacity and space restrictions in the major urban areas, implementation will be in stages to ensure high quality of services are delivered to all children. At the beginning of the Project implementation, priority will be given to children belonging to the most vulnerable families identified by the Project as they are the ones in most need of support. Where capacity is available, preschools will be open to enroll children up to their capacities, according to the government’s regulation on numbers. 19. Implementation. The intervention will provide children with exposure to a play-based curriculum in a classroom setting, providing them with a learning experience that will address various aspects of child development, including fine motor skills, hand eye coordination, language skills, social skills such as co-operation and taking turns to build up their confidence, as well as problem solving skills. Teaching aides will be hired and trained by the Project to manage and facilitate the activities in the classroom and ensure the child:educator ratio is appropriate for the target age-group. MOEST/PSS mandates a 30:1 student:teacher ratio for kindergartens, but as they do not yet have a mandate for children 1 WUTMI is an independent, registered non-governmental organization. Page 60 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) under 5, TA will be provided by the Project to assist MOEST/PSS to identify an appropriate ratio for the younger age group. Preschools will be opened one session a week to allow caregivers to join learning by playing activities with children. 20. The creation of public preschools will include: (i) identification and preparation of venues for preschools; (ii) provision of age-appropriate furniture and facilities to equip the learning spaces; (iii) selection and recruitment of teaching aides; (iv) development and production of materials and resources required for play-based activities; (v) provision of training for teaching aides to equip them with the knowledge and experience to be able to organize and run the classroom, and to engage parents during open sessions; and (vi) identification and training of coaches to support teaching aides. 21. Venues. MOEST/PSS has identified four public elementary schools in Majuro with unused classrooms that could be used to set up preschools in the early stages of project implementation. It is also anticipated that identifying space for pre-schools on the outer islands should not be a major challenge due to the small population densities there. However, in the two main islands of Majuro and Ebeye with high population densities, innovative solutions will be required to maximize the use of other spaces to increase access of preschool for 3-4-year-old children. TA will be provided during the first year of implementation to assist MOEST/PSS to identify viable solutions. Personnel, resources, training and monitoring 22. Personnel. Selection and recruitment of teaching aides and coaches will be the responsibility of the MOEST/PSS based on the terms of reference for each job, and WUTMI or other selected home visit agency will be responsible for the selection and recruitment of parent educators. Teaching aides will be contracted by the government under PSS and receive a monthly full-time salary in accordance with the MOEST/PSS salary scales. Coaches will be selected from the existing teaching workforce in RMI, though some additional coaches may be required. Parent educators will receive the same per-visit stipend currently paid by their organization. It is expected that contract providers will be absorbed into the MOEST/PSS payroll during the life of the project. Therefore, the number and type of additional contract staff will be included in the annual work plan and budget, and jointly agreed between the Government of RMI and the WB. 23. Resources. The Project will support the development, production and purchase of materials, which will be made available for preschool classrooms and parent educators, each receiving materials relevant to the activities they are implementing. TA will be available to work with government agencies and training partners in developing and/or procuring materials and resources to ensure they are relevant and appropriate for the country context, and achieve the Project’s intended objectives. This would include: parent educator’s guide on conducting home visits and setting up and organizing community playgroups, and teaching aide guides on play-based learning and conducting parenting sessions; materials for play-based activities and parenting education on ECD; reading materials available for young children that parents and children could borrow to read together at home; play-based educational resources for classrooms and that could be provided to families; and other consumable resources for classrooms and playgroup activities. Procurement of all items will be carried out by the procurement consultant housed in the PIU. 24. Training. TA will be engaged to review, develop and adapt training materials that are relevant and appropriate to the country context. All personnel involved in supporting and running the preschools and home visits will receive relevant training to ensure they are fully equipped to deliver high-quality ECD services. This will include MOEST/PSS personnel involved in implementation and monitoring of the classrooms, coaches, teaching aides, and parent educators. Training will be tailored for each target group according to its tasks, responsibilities and accountability for Project execution. Given the country context and lack of implementation capacity, training could be delivered through existing arrangements between the government and training providers, such as USP (Majuro campus) or College of Marshall Islands. Training will be delivered using the materials developed and adapted for the Project while ensuring a career pathway for teaching aides and parent educators who could gain training credits over the years of Project implementation to obtain a certificate and/or eventually a degree in the field of ECD. The length of the training for each stakeholder is to be decided based on a needs analysis and cost estimate. Depending on the needs identified during implementation, refresher training sessions could be provided in which teaching aides and parent educators would come together to reflect on their Page 61 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) experiences, exchange new ideas, and share lessons learned among them. Innovative training approaches could be explored to guarantee high quality of training delivered to teachers, especially those serving schools in outer islands. Some training sessions will see overlaps between each of the target groups, and training providers will assist to identify these overlaps and combine sessions where appropriate and feasible. Exchange visits could also be organized to facilitate good practices among different regions of the country and study visits overseas, if appropriate and necessary. 25. Coaching. Training will be most effective only if teachers have opportunities to practice knowledge and skills received from training. Therefore, regular support and coaching visits to kindergartens and home visits will be undertaken during implementation to maximize the knowledge and skills received from training. The Project will provide support to train a group of expert coaches to conduct regular coaching visits to preschools and home visits to provide support to teaching aides and parent educators. A coaching instrument will be developed to monitor trainees’ progress and will be used to identify further training needs. 26. Monitoring. The current suite of forms used by WUTMI or other organization undertaking home visits will be reviewed and modified as needed, and training provided to relevant staff involved in implementation of the home visit program, including parent educators, to ensure understanding and correct use of these forms. Similarly, the Project will prepare administrative forms for implementation progress monitoring of preschools. During the first year of implementation, an international consultant will conduct an assessment and propose feasible and relevant options for possibilities of applying ICT in implementation of monitoring to be supported by the Project to ensure accuracy and reliability of information and data collected. All stakeholders involved in Project implementation will receive training according to each person’s responsibility to collect information and data. A focus will be monitoring compliance of the beneficiary groups for the CCT pilot (see component 3 for details). Component 3: Social assistance for early years’ families (Total US$3.46 million, of which IDA: US$2.91 million, Government: US$0.55 million) 27. Component 3 aims to increase utilization of key ECD services using CCTs as a means to modify care practices and behaviors. Cash transfers would not only directly address financial barriers to accessing key ECD services (e.g. transport and opportunity costs)2, but also be instrumental in addressing cultural and motivational barriers to access in the longer term. The guiding principle of this component will be to incentivize the utilization of, and regular participation in, ECD services offered through the Project. This component would also begin the process of building up a social assistance system in the RMI to drive the ECD agenda. 28. Component 3 has two sub-components, one aimed at providing TA to establish the social assistance system, and the other aimed at the provision of cash transfers to beneficiary families. 29. Sub-component 3.1: Strengthening the RMI Government’s capacity to establish and deliver social assistance program for ECD. This sub-component will finance TA activities to support the development of (i) a beneficiary registry; (ii) MIS for targeting, registration, compliance verification, payments, and case management; (iii) a GRM (beneficiary feedback, appeals and complaints); (iv) setting out the guidelines for an M&E framework; (v) a communications strategy for the social assistance program including SBCC and its implementation; and (vi) support to administrating the program in Majuro and Ebeye including the development of a training strategy and plan for MOCIA staff and field officers. The program will also need to set up MOUs with MOHHS, MOEST, MISSA and MALGOV for activities, including beneficiary outreach and identification and monitoring of conditionalities. The Project will strengthen national registry systems by requiring family members to produce birth certificates and national identification/social security number to enroll into the program, aiming at validating identity and avoiding multiple applications using different forms of identification. Additional details of the cash transfer pilot 30. Communications. A public communications campaign needs to take place in Majuro and Ebeye, to convey the objectives of the program, clear eligibility criteria and areas of intervention. The program will start as a pilot and it is 2 ANC visits, vaccinations and growth monitoring visits are free of charge. Page 62 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) crucial the public is well informed on the activities of the program. Messages can be transmitted via radio and newspapers. MALGOV and council persons will support this activity by conducting community outreach activities. The program will also hold SBCC sessions for the families on various topics regarding ECD. 31. Targeting. Due to the low levels of service utilization for the poorest and most vulnerable populations, the Project will aim at targeting families facing hardship in Majuro and Ebeye having pregnant women and children aged 0-59 months old. Additional geographic areas may be included if additional funds become available, and if agreed between the Government of RMI and the WB. The MOCIA has agreed to consider introducing some basic form of vulnerability and hardship targeting of beneficiaries which would include development of a localised vulnerability and hardship criteria which would lead to the development of a simple family assessment survey to be completed by MOCIA in order to establish eligibility of families facing hardship3. 32. Personnel. The project will finance contracted CCT program officers to conduct the family assessment survey and support registration, compliance verification, payment, case management, monitoring and evaluation, and administration for the CCT program. It is expected that contract providers will be absorbed into the MOCIA payroll during the life of the project. Therefore, the number and type of additional contract staff will be included in the annual work plan and budget, and jointly agreed between the Government of RMI and WB. Two ECD Coordinators (national and international) will be placed within the MOCIA, who will not only be responsible for managing activities under the Ministry’s mandates (as discussed under component 4), but in doing so will provide specific guidance to staff in the ministry and other implementing agencies to build capacity to work on their mandate in the future. It is expected that the national ECD coordinator will be absorbed into the MOCIA payroll during the life of the project (approximately year 4). 33. Registration. Eligible family members will need to meet the following conditions to be registered in the CCT pilot: (a) families facing hardship; (b) live in the Project implementation area; (c) pregnant women and children between 0-59 months; and (d) national ID for caregivers, and birth certificates for children. Families will need to apply for the benefit, and if they comply with the criteria, they can be enrolled into the program. During registration, families will be required to sign a beneficiary agreement. The family will designate the mother or a caregiver as the receiver of the cash transfers. The program will prioritize the mothers or female caregivers of the children, as a way to maximize the impact of investments in human capital. 34. Compliance verification of conditions. As mentioned earlier, the CCT will include soft conditions during the first year. Families will be notified that they should enroll their children in ECD sessions, complete vaccinations schedules and take children for child well visits; in addition, pregnant women should attend the medical health facility for ANC visits and make sure birth certificates are issued for the child once born. For monitoring and compliance verification of the families, the MOCIA will closely liaise with the MOHHS, MOEST/PSS and the Health, Education and Social Affairs (HESA) division of MALGOV to seek support in coordinating with pre-schools and health facilities for admission verification and attendance records of the beneficiary families. If families do not fulfil the conditionalities for six-twelve months, a field officer will conduct a “lack of compliance” visit to ascertain/address the reasons for not complying. The family will be given a maximum of three warnings before the conditional benefit (e.g., education and health) ceases. 35. Payments. This payment cycle comprises the following processes: (a) generation and transfer of payroll; (b) transfer of funds to MOCIA; (c) transfer of funds to payment service provider; (d) delivery of cash transfers to beneficiary families; and (e) reconciliation of payments (paid vs. unpaid benefits). Reconciliation and liquidation of payments and financial reporting procedures will be done in accordance with program FM requirements as established in the financial institution agreement. 36. Case management and GRM. Case management and the GRM would address issues (cases) related to updates of household information, appeals by families not selected into the CCT pilot, and complaints about payments, and quality of service. The objective is to receive, process, and track complaints and claims of the families benefiting from the 3 A hardship scoring method can be used based on the variables of the HIES to assess socio economic status of families. Page 63 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) program to improve and streamline services. 37. In the program, a ‘complaint’ is defined as unsatisfactory service either related to CCT implementation or payments. The case management scheme for the CCT includes decentralized and centralized processes using the MIS of the program. The GRM system will clearly indicate the type of complaints for the program. Beneficiary feedback will also be part of the GRM. 38. MIS. The MIS is the most critical tool for efficient and effective implementation of the CCT. The MIS will allow the MOCIA to manage the Project in all key phases of the operating cycle including determining eligibility, registration, compliance, monitoring, case management, and payments. In addition, the MIS will support the MOCIA team to produce the required reports on Project progress. The MIS will be the responsibility of the MOCIA and should be developed by highly trained information technology/MIS experts who are qualified and experienced in developing social assistance MIS. The experts will support the development, launching, and training of officers in the use of the MIS. The development of the MIS will be done by using the Project management principles to support those responsible for managing and operating the system, ensuring transparency, efficiency and credibility of the program. 39. M&E. An important component of the program is the M&E, which will be conducted through various methods at each level of the Project. The objectives of the CCT pilot M&E are to (a) monitor the progress of the CCT pilot implementation; (b) check the operational efficiency of the program; (c) document and disseminate lessons learned from program planning and implementation; (d) measure the progress of output and outcome indicators against program objectives; and (e) provide evidence regarding the effectiveness of the program (through an IE) for possible scale-up and inform if any changes in design and implementation arrangements are needed for the scale-up process. A third party will be hired to conduct the baseline and subsequent impact evaluations over the course of the Project life. 40. Sub-component 3.2: Provision of cash transfers to early years’ families in selected areas. Families in selected areas of Majuro and Ebeye with pregnant women and children aged 0-59 months who are facing hardship would be eligible to enroll in the program. Additional geographic areas may be included if additional funds become available, and if agreed between the Association and the Recipient. The CCT pilot will aim to target the most vulnerable families in Majuro and Ebeye by developing a localized vulnerability and hardship criteria, which would target (at least ten percent (10%)) of the total families living in the target areas based on the proportion agreed on between the Government of RMI and the Bank. The payments will be channeled to the mother or caregiver of the children. Due to the lack of updated HIES data, the benefit level will be set using the informal minimum wage4, which is equivalent to roughly 10 percent, or approximately US$30 per month, as a base benefit given to the mother or caregiver (unconditional amount), plus US$3/child up to a maximum of 3 children per month, as a bonus amount based on meeting program conditionalities. Cash transfers will be paid every two months to provide regular and predictable transfers to families and thus smooth consumption. The program will be managed by the MOCIA’s Community Development Division 41. Given that banking and financial services are limited in the RMI, the payment mechanisms will need to use banking services that are available from the BOMI. The post office does not offer money transfer services, and Money Gram and Western Union only offer international transfer services. Internet connectivity in the RMI is also very limited due to affordability and reliability issues, making mobile banking also an unfeasible option. There are two main banks, the Bank of Guam and BOMI. Payments can be made through BOMI since it has more branches in the country and is regulated by the Banking Commission of the Marshall Islands. Beneficiaries will need to open an account and withdraw the benefit at a BOMI branch5. The Government has indicated their preference to make electronic payments to the beneficiaries under the program and will be working with BOMI to facilitate the process. 42. The cash transfers will include a base payment which will be unconditional, and a bonus payment which will be 4 The informal minimum wage rate in the RMI ranges between US$300 and US$500 per month. The lower range of US$300 was used to calculate the base benefit for the CCT. 5 Discussions with BOMI included waiving the fees for opening accounts and account maintenance and no minimum balance required for beneficiaries, which is US$125. Transaction costs will need to be negotiated with MOCIA. Page 64 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ‘conditional’ on families being enrolled in the program and attending the predetermined schedule of health facility visits on a regular basis and achieving at least 75 percent attendance of the ECD sessions. The program will have soft conditionalities during the initial phase: program co-responsibilities and compliance of conditions will be communicated to beneficiaries but not enforced. This initial phase will involve significant capacity strengthening, including the development of the MIS and MOUs to clearly delineate the roles of MOCIA, MOEST, MOHSS, MALGOV and MISSA. Once the public is well informed about the program and the capacity is developed, the program can start applying hard conditionalities, whereby the conditions will be monitored and enforced, and families penalized for non-compliance. 43. In its initial phase, the program will pilot the cash transfer model in Majuro and Ebeye, followed by close third- party program monitoring through process evaluations, spot checks and an impact evaluation after the first complete year of program implementation. These evaluations and the SBCC activities will provide the necessary information on beneficiary behavior, household dynamics, spending behavior and emerging program impacts which could inform the functioning of the program, and support the national roll-out of the social assistance program. Component 4: Strengthening the multisectoral ECD system and Project Management (Total US$3.44 million, of which IDA: US$3.27 million, Government: US$0.17 million) 44. Component 4 will finance the systems functions and activities necessary to sustain an effective multisectoral ECD program. These functions include: (a) development of a multisectoral national ECD strategy and approach to program implementation; (b) development of a national monitoring, evaluation, and learning framework and implementation of the system; and (c) the preparation of a national communication strategy for ECD and the delivery of public awareness and SBCC campaigns. The component will support the OCS in leading and coordinating an ECD program based on evidence-based best practice through TA activities and support for operational costs. It will aim to increase program effectiveness by: ensuring line ministry activities are underpinned by a strategic approach to program implementation; creating and using data for decision-making; and harmonizing communication activities and messages across various channels. 45. Sub-component 4.1: National Multisectoral ECD Strategy and Governance. Sub-component 4.1 will finance TA to develop RMI’s National Strategy for ECD. The strategy will define clear objectives for the national ECD program, describe key activities and interventions, and clearly delineate the roles and responsibilities of the main actors and governance mechanisms. It will further support OCS and the CC in leading ECD program governance and coordinating implementation across key line ministries, such as MOF, MOEST/PSS, MOCIA and MOHHS. This sub-component will finance the TA and operational costs needed to develop the strategy and conduct periodic implementation reviews, as per agreed governance arrangements. 46. Monitoring, Evaluation and Learning (MEAL). Sub-component 4.1 will also finance the development and operationalization of a comprehensive ECD monitoring, evaluation, and learning (MEAL) framework. MEAL activities will assess the performance of the ECD program using adequacy and/or plausibility evaluation and promote adaptive learning throughout program implementation over time. The MEAL platform will consolidate indicators of service provision, quality, utilization rates, drawing from the three implementing line ministries’ (MOHHS, MOEST, MOCIA) routine data collection systems to the extent possible. Sub-component 4.1 will finance activities and inputs above and beyond investments in line ministry data and information systems under components 1-3, including activities to enable EPPSO to support ECD program monitoring and evaluation. The sub-component will finance a MEAL Coordinator to support the PIU and: (i) develop the MEAL framework; (ii) convene regular MEAL reviews; and (iii) build line ministry capacity to produce quality ECD program data. Further, it will finance monitoring of child development outcomes in cohorts over time, either through surveillance methods or appending appropriate child health, nutrition, and development modules to population-based surveys, as feasible6. The sub-component will finance TA to each line ministry to conduct rapid/process/qualitative assessments during implementation, including beneficiary assessments of knowledge and 6Including ongoing discussions to assess anthropometric status and child development in a subset of the 2019 Household Income and Expenditure Survey (HIES) sample to use as a project baseline. Page 65 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) practice. These assessments will aim to document program challenges and successes and incorporate feedback loops that can contribute to continuous improvement of intervention design and implementation. 47. Sub-component 4.2: ECD Awareness and SBCC Campaign. Sub-component 4.2 will finance communications, advocacy, and awareness-raising activities for the ECD program. A centralized approach to the development of communications and advocacy materials is intended to promote linkages across the components and ensure consistency of messages. The sub-component will finance: (i) a SBCC and Advocacy Coordinator to provide centralized strategic and technical leadership to the development, implementation, coordination, and monitoring of ECD advocacy, awareness raising, and SBCC activities; and (ii) development of a SBCC strategy and associated campaign content intended to increase the intensity of intervention and exposure to campaign messages. The SBCC and Advocacy coordinator will work with the relevant line ministries to ensure buy-in and consistency of messages and activities across channels. 48. Achieving optimal child health, growth, and development in the RMI is dependent on changing behaviors. Evidence indicates that a multichannel approach, including mass media, interpersonal communication and counselling, community-based interventions, and community and social mobilization can be effective in changing behaviors related to infant and child care and nutrition. To support this, a robust, contextually/culturally/linguistically relevant SBCC strategy and associated campaign content developed to increase the intensity of intervention and exposure to campaign messages. It is anticipated the SBCC will be comprehensive, with content including elements such as maternal, infant, and young child nutrition; water, sanitation and hygiene; health care seeking; parenting; early stimulation; and early learning, with messages defined based upon delivery channel. The development and coordination of SBCC activities for ECD will be the responsibility of the OCS with support from the ECD PIU and SBCC and Advocacy Coordinator. Sub- component 4.2 will support the development of the SBCC strategy and campaign content; delivery of SBCC through mass media channels; and cross-sectoral coordination and monitoring. Sub-component 4.2 can also finance additional formative research required to improve the relevance of messages and implementation approaches. Each implementing line ministry will be responsible for implementing SBCC activities through their respective channels (see Table A2.2). Attention will be paid to ensure that there are links and reinforcement of nutrition and stimulation messages across components 1 and 2. Page 66 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Table A2.2: SBCC Activities and Channels Across Project Components Component Activities and Channels Component 1 • Production of materials for the health sector; training of health personnel in delivery of the component 1 SBCC package • One-to-one interpersonal communication during ANC, deliver, postnatal care, and well/sick child visits • Group interpersonal communication at health facilities and in communities Component 2 • Production of materials for the education sector; training of education personnel in delivery of the component 2 SBCC package • One-to-one interpersonal communication during home visits • Community-based activities for home visit beneficiaries • Group interpersonal communication at kindergartens Component 3 • Production of materials for MOCIA; training of cash transfer personnel in delivery of the component 2 SBCC package • Community gatherings linked to cash transfer payouts Component 4 • Development of SBCC Strategy • Development of SBCC content for all channels • Development of SBCC monitoring, supervision, and coaching guides • Development of social and community mobilization approaches • Mass and social media campaigns • Social mobilization activities • Multisectoral ECD Community gatherings • Targeted ECD advocacy to improve the enabling environment 49. Sub-component 4.3: Project management. Under this sub-component, the PIU will be established with specific responsibilities to support and coordinate implementation of Project activities. The PIU will support the OCS in its leadership of the ECD program and enable coordination across key line ministries, such as MOF, MOEST/PSS, MOCIA and MOHHS. The PIU will work in coordination with the CIU in MOF for FM, procurement, safeguards, communications, and monitoring. The sub-component will finance (i) external consultancies required for ongoing Project staffing; (ii) technical consultancies required for adherence to program operations and procedures; (iii) office and other equipment; and (iv) travel and operational costs. Detailed discussion on the ECD PIU and multi-sectoral coordination is provided in Annex 1. Page 67 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ANNEX 3: Technical, Economic and Financial Analysis COUNTRY: Marshall Islands Multisectoral Early Childhood Development Project Economic and Financial Analysis 1. Activities targeted to the early years are among the most cost-effective interventions and an increasing volume of research has been successful at documenting the high returns on these investments (Kilburn and Karoly 2008). Activities included under this Project have been selected drawing from global evidence and prioritizing cost-effective interventions with high returns on investments. 2. There are several channels through which investments in the early years yield economic benefits and promote growth. Firstly, ECD Projects contribute to improvements in cognitive skills, socio-emotional development and school readiness. Moreover, there is evidence to suggest that early childhood stimulation and play-based learning can both help the transition into the workforce later in life and increase wage earnings by up to 25 percent. Impact evaluations further hint to positive long-term effects (e.g. increased higher-education completion rates) (Molina Millán et al. 2018).The rate of return on investments to ECD interventions depends on multiple factors, but they have been shown to have benefit- cost ratios as high as 17:1. The economic return to these investments, compared to the cost of service provision, is significant across all countries where rigorous impact evaluations have been undertaken: increasing enrolment rates to 50 percent in pre-school programs for children ages 3 and 4 in middle-income countries is associated with benefit-to- cost ratios ranging between 6.4 and 17.6 depending on discount rates and on the enrolment rate achieved (Engle et al. 2011). Furthermore, evidence from Jamaica suggests that there are benefits from designing ECD interventions that include parenting aspects. Gertler et al., for example, found substantial effects on labor market outcomes from early stimulation through parental interventions. Secondly, ECD interventions yield economic benefits by increasing parental participation in the labor market. Pre-school activities provide custodial care and therefore allow parents to engage in income-generating activities (IDB 2015). 3. Cost-effectiveness of child health interventions is also very high. Evidence from the global investment framework for RMNCH suggests that one dollar invested in the essential package of maternal and child health and nutrition interventions brings about US$9 dollars in economic benefits. Particularly cost-effective interventions include nutrition activities such as zinc added to oral rehydration therapy, micronutrient interventions and community management of severe malnutrition, and health interventions like maternal and neonatal care at home (Horton and Levin 2016). Investments in family planning and reproductive health yield further benefits through the demographic dividend effect. 4. CCT programs can leverage the economic benefits of other investments in human capital and can further generate economic gains, both at a household and at a country level. At the individual level, these programs offer protective benefits through consumption smoothing. A systematic review of CCT programs also found significant effects on poverty alleviation, school attendance, health utilization and outcomes, saving, investments and employment (Bastagli 2016). At the country level, investments in CCT generate economic benefits by increasing access to financial services and linking families with the banking infrastructure7. Furthermore, given that holding a recognized identification document is a requirement for enrolment into most CCT programs, these interventions have a positive impact on the coverage of National ID services. In addition, evidence shows that CCT programs combined with ECD interventions that include parents improve parental practices and improve development outcomes (Arriagada et al.). 5. The lack of data in the RMI hinders the performance of standard economic analysis assessments such as cost- benefit analysis. These assessments are used to determine whether the Project’s benefits are expected to exceed its cost, 7 At present BOMI only has 10,000 clients. Page 68 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) and to establish cost-benefit ratios that can help appraise the Project’s return on investment. Cost-benefit analyses consist of three main steps: (i) discounting the Project’s costs throughout the life of the Project8; (ii) calculating the Project’s benefits and monetizing them; and (iii) calculating cost-benefit ratios9. While the Project’s costs can be discounted, the lack of data in the RMI poses serious challenges to the estimation of the Project’s potential benefits. Given the complexity of some of these calculations, tools – such as One Health and Spectrum in the health sector - have been developed globally to support this process. Unfortunately, none of these tools has default information for RMI. 6. The small size of the population and the high cost of delivering services in the RMI might reduce the cost- effectiveness of ECD and nutrition interventions. While global estimates described above clearly reflect that ECD and nutrition interventions are highly cost-effective, small population sizes can reduce economies of scale in delivering these interventions. Furthermore, the RMI’s remote location and complex geography increase the cost of delivering services. It should be noted, however, that cost-effectiveness is judge relative to a country’s GNI per capita. With a GNI per capita of US$5,016 in 2017 (Pacific and Virgin Islands Training Initiatives 2017), even with modest increases in cost-benefit ratios, interventions financed under this Project are expected to be cost-effective. 7. By and large, the potential economic cost of failing to improve ECD and nutrition outcomes in the RMI is significant. At the individual level, chronic malnutrition in children is estimated to reduce a person’s potential lifetime earnings by at least 10 percent (World Bank 2006). With one-third (35 percent) of children under 5 experiencing low height-for-age (an indicator of chronic malnutrition), the aggregate potential earnings lost annually is immense. The poor supply of RMNCH- N services and early learning activities in RMI has implications for the cognitive, linguistic and socio-emotional development of individuals and long-term physical well-being and growth. The economic costs are large and disproportionately impact the most vulnerable, with child stunting prevalence twice as high among children in the poorest households (44 percent), compared to the wealthiest (20 percent). This has the potential to trap generations of individuals and communities in a cycle of hardship. 8. Relatively modest investments in the supply of RMNCH-N services and early learning activities will pay large economic dividends. At present, there is limited availability of reproductive, maternal, newborn and child health and nutrition services, particularly for those in the OI. Rationale for government intervention 9. There are several factors that justify government’s interventions in ECD. Public sector provision and financing of ECD and nutrition services can be justified where market failures clearly exist. In the context of the RMI, these include: the lack of availability of widespread quality public ECD and nutrition services; uncertainty about or lack of information on the benefits of ECD; and imperfect parenting (parents unavailable, unhealthy, or uncaring). 10. The set of ECD and nutrition interventions proposed under the Project are considered public goods with positive externalities. Promoting these interventions through the free market may lead to inadequate supply and utilization, negatively affecting human capital accumulation and productivity at the macro level. Public financing is thus needed not only to improve the public’s skills and productivity, but also to reduce future health care costs and their potential downside impact on the economy. 11. Public financing and provision are necessary to improve both the efficiency and equity of service delivery. Global evidence points to the ripple effects of investments in early child development (including health and nutrition interventions targeted to children) on economic development later on in life. This, together with the fact that return to investments made later in life can be lower, provide a strong business case for ECD. Moreover, research shows that disparities in development outcomes can be observed before year 5, when children join the education system. As a 8 Using a 3 percent discount rate, the project’s present value is US$10.8 million. 9 A review of selected World Bank projects focused on improving RMNCH outcomes revealed that cost-benefit ratios ranged from US$2,789 per averted death in the Accelerating Nutrition Results (P162069) project in Nigeria and US$38,583 per averted death in the Investing in Maternal and Child Health (P162042) project in Senegal. Page 69 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) consequence of this, government interventions in ECD can have a strong equalizing effect. Furthermore, remedial interventions (e.g. special education programs) are less cost-effective than ECD programs. 12. The private sector does provide certain services in the RMI; however, as the immediate returns are low, there is chronic underinvestment and availability is relatively limited. Pre-school for 3-4-year-olds is only privately provided and covers approximately 5 percent of the population. Those from poor families are less able to access these privately provided services. Moreover, families in the OI are at a distinct disadvantage both in terms of access to information about ECD services and in their ability to access them affordably (service fees are low, but transport costs pose a significant barrier). In addition, it should be noted that evidence shows that public investments in early child development do not crowd out private investments (Berlinski, Galiani, and Gertler 2009; Bastos and Straume 2013). Fiscal impact of the Project 13. Economic growth accelerated in 2016 and macroeconomic forecasts predict continuous economic growth over the next five years (see Figure 3). According to the International Monetary Fund (IMF), growth rates are expected to revolve around 2.5 percent over the near term and remain positive (but lower) over the medium term. Furthermore, RMI faces a fiscal surplus of 3 percent of GDP, which this is expected to narrow in the future as a result of increased government spending and stagnant revenues. Achieving a balanced budget is of paramount importance for the Government of the RMI. In fact, it has been identified as a guiding principle in fiscal policy-making in the Financial Management Act of 1990. This is explained by the fact that RMI’s small and undiversified economic base increases the country’s vulnerability to the volatility in the few sectors that drive economic growth and to changes in the global economy. Figure A3-1: Trends and projections in annual GDP growth (% change) 4.0 3.5 3.0 Real GDP (% change) 2.5 2.0 1.5 1.0 0.5 0.0 -0.5 -1.0 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 (e) (p) (p) (p) (p) (p) (p) Source: Article IV (IMF) Note: e = estimated; p = projected 14. The Project’s grant financing contributes to the Government of the RMI’s efforts to promote fiscal sustainability and growth. Despite having a comparatively low debt-to-GDP ratio (see Figure 4), the RMI is considered at high risk of debt stress. According to the IMF Article IV consultations, debt servicing risk is low given the high revenues generated by the fishing industry and the stable flow of funds from the US Compact Grant10, but the RMI’s debt position is susceptible to stress if there are changes in lending conditions, and it is highly vulnerable to macroeconomic shocks. Mitigating strategies to contain debt-related risks include the use of concessional and grant financing and the implementation of fiscal reforms to increase revenues and reduce expenditure, as well as Public Financial Management (PFM) reforms to 10Compact Grant assistance is provided by the Government of the United States to RMI, the Federated States of Micronesia (FSM) and the Republic of Palau. This support is provided on a sector basis, including education, health, private sector development, capacity building in the public sector, environment and public infrastructure. Funding for FSM and RMI is planned until 2023 (US Department of Interior). Page 70 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) improve the efficiency of public spending. Nevertheless, Article IV consultations emphasize the importance of safeguarding social spending from structural adjustment efforts. Figure A3-2: Total Public Debt in Pacific Countries Source: Article IV (IMF) 15. In 2014 the Government of RMI prepared the Decrement Management Plan to reduce government spending by 15 percent between 2016 and 2023. The plan focused on three sectors, namely Government Administration, Health and Education. Almost half of the cuts (which total US$6 million) were planned for the Government Administration sector. In 2016, nevertheless, education and health remained a priority for the Government of RMI and they absorbed the highest share of public funding, with roughly 21 percent of government spending allocated to each sector. While official estimates foresee a significant decline in funding for the health sector in 2019, financing for the education sector is expected to remain stable. MOCIA, in turn, receives a small share of the budget. In 2016, the Ministry’s expenditure represented only 2 percent of total government spending (Budget Book 2016-2021). 16. It should be noted that the availability of financial data in the RMI is limited11. The low level of disaggregation of budget and expenditure data hinders the performance of financial analyses and represents a significant constraint to more detailed assessments of the financial implications of this Project. Health spending 17. Investments proposed under this Project represent a marginal share of the sector’s budget. With average yearly estimated disbursement of US$600,000, the Project would constitute an increment of 2.3 percent in the health budget. Moreover, these investments will not lead to high incremental costs in the near- or medium-term. Capital investments under the Project will be limited to the purchase of basic equipment. Maintenance of such equipment will only require minor investments, and these will not exert pressure on the budget of the MOHHS. Investments in human resources will represent roughly 60 percent of all investments and include 3 nurses for Majuro hospital and 3 nurses for Ebeye hospital, as well as 2 certified nurse midwives. With 520 public servants in the payroll of the MOHHS, this will represent a 1.5 percent increase in the workforce and contribute to a yearly increase in the sector’s budget of 0.8 percent. Education spending 18. The Multisectoral ECD Project will provide additional US$600,000 on average every year to the education sector. Compared to 2016 spending data, this represents an increase of 2.4 percent. Capital investments will be limited to the procurement of basic equipment and the expansion of public elementary schools to cater for children age 3 to 4. The exact impact of these investments on the cost of utilities and the maintenance budget cannot be estimated given the lack of relevant data, but the nature of the equipment (basic equipment with marginal investments in maintenance required) and the small scale of the infrastructure upgrades suggest that the impact will be small. 11For example, there is no information available on budget execution rates to judge the capacity of the Government of RMI to absorb additional funding. Page 71 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) Social protection spending 19. The Social Assistance component of this Project will contribute approximately US$450,000 every year, which represents 18.6 percent of the MOCIA’s budget. While these investments do not create potential incremental costs in the future, there is a risk that the MOCIA will not have the financial management capacities to administer these funds efficiently and effectively. To mitigate this risk, Project funding will be utilized to cover the running costs and the salaries of the staff required to implement the Project, at least during the first 5 years of implementation. Staff costs, including the salaries of local and international staff as ECD Program Officer, an SBCC and Advocacy coordinator, a M&E coordinator and a program officer, amount to almost one million dollars a year, represent a significant incremental recurrent cost. Building the capacity of the local staff to carry on these activities after the Project finishes will be of utmost importance to ensure the financial and institutional sustainability of these interventions. 20. Overall, the financial impact of the Project on the Government’s fiscal position is expected to be limited. While the nature of the activities financed under the Project suggests that incremental recurrent costs due to these investments will be small, it will be important to support the Government in the identification of resources to absorb the additional staff after Project funding ends. Furthermore, given potential budget cuts planned under the Decrement Management Plan, the Project will monitor the RMI’s fiscal trends to ensure that, in the event of significant cuts, the financial pressure remains low. Technical Analysis 21. The Project builds on the global evidence surrounding the importance of investing in the early years. Guaranteeing that every child has adequate access to education, health, nutrition and protection in the early years ensures that they have the required foundations for developing skills and are ultimately able to access jobs in the future (World Bank 2018). Improving these outcomes, especially in the first 1,000 days, is critical for addressing the World Bank Group twin goals of reducing poverty and boosting shared prosperity. The returns to investments in children’s early years are substantial, particularly when compared to similar investments made later in the life cycle (Heckman and Masterov 2007). Intervening during early childhood clearly has the potential to mitigate the negative effects of poverty and promote equitable opportunities and better outcomes later in life (Heckman 2008). The Project addresses the key areas of the WB’s Investing in the Early Years Conceptual Framework while strengthening the system to ensure continuum of care and coordination of services. 22. Delivering ECD and nutrition services through a multi-sectoral program approach. The program will employ a multi-sectoral response to achieving improvements in children’s physical, cognitive, and non-cognitive development. The program will consist of two phases, initially leveraging the existing services and platforms, sequentially expanding the scope and quality of early years services, and simultaneously strengthening the institutions and systems necessary to institutionalize the service delivery platforms. Over time, these newly developed platforms will stimulate demand and behavior change among families and communities. The multi-sectoral program approach allows for adaptive learning of different service delivery approaches and their applicability to the RMI context. 23. The provision of CCTs would serve to improve the demand for these services and therefore compound the development impacts associated with their provision. The economic benefits of this type of intervention are expected to be twofold: (a) by incentivizing the uptake of ECD and nutrition services, this will improve children’s educational and health outcomes, and therefore projected wage earnings over their life cycle; and (b) by providing direct monetary transfers to families, there will be an immediate impact on poverty rates at the household level. The costs are derived from the actual cash transfers, associated administrative costs for their provision, and potential inflationary effects for non-beneficiaries (higher costs for food items, for example). Page 72 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) World Bank Value Added 24. The WB has extensive experience in addressing ECD and nutrition issues and has gained considerable experience in preparing multi-sectoral early years programs, focusing on health, nutrition, education and social protection. The WB brings global knowledge and experience to the development of nutrition-sensitive operations which use an integrated approach to improving health, nutrition and child development outcomes. These integrated approaches involve the use of community-based interventions linked to strengthening access and delivery of services and are supported by social and behavioral change interventions (Indonesia, Madagascar, Cote d’Ivoire). The use of cash transfers in these operations is also becoming an increasingly popular instrument for nudging family spending towards nutritious and healthy choices (Indonesia, Myanmar). The WB has also amassed considerable regional experience in the Pacific, with on-going health and nutrition operations in PNG and Solomon Islands. The WB is a pioneer in ECD and early learning through the Pacific Early Age Readiness and Learning Program which covers three PICs, including Tonga, Tuvalu and Kiribati. The WB has also recently prepared a lending operation in Tonga (Skills and Employment for Tongans) that includes CCT for secondary school students, which is in addition to its long-standing TA engagement in the Pacific on social protection, with in- country engagements in Fiji, Tonga and Papua New Guinea. The WB offers predictable, stable financing in a sector which has traditionally been underfunded in RMI. Moreover, the WB’s assistance will be well coordinated with support provided through other development partners, such as the Australia’s Department of Foreign Affairs and Trade, and UNICEF, and therefore complement, rather than supplant, existing areas of support. Page 73 of 74 The World Bank Multisectoral Early Childhood Development Project (P166800) ANNEX 4: Map of the Republic of the Marshall Islands Page 74 of 74