FOR OFFICIAL USE ONLY Report No: PAD2972 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 21.6 MILLION (US$30.0 MILLION EQUIVALENT) TO THE REPUBLIC OF BURUNDI FOR THE INVESTING IN EARLY YEARS AND FERTILITY IN BURUNDI PROJECT (NKURIZA) August 14, 2019 Health, Nutrition and Population Global Practice Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective 30 June 2019) Currency Unit = Burundian Franc (BIF) US$1 = BIF 1837 US$1 = SDR 0.719 FISCAL YEAR July 1 – June 30 Regional Vice President: Hafez Ghanem Country Director: Jean-Christophe Carret Senior Global Practice Director: Muhammad Pate Practice Manager: Magnus Lindelow Task Team Leaders: Laurence Lannes, Alain-Desire Karibwami ABBREVIATIONS AND ACRONYMS ASA Advisory Services and Analytics AWPB Annual Work Plan and Budget BCC Behavior Change Communication BIF Burundian Franc CBA Cost-benefit Analysis CBFP Community Based Family Planning CDD Community Driven Development CERC Contingent Emergency Response Component CHW Community Health Workers C-IMCI Community- Integrated Management of Childhood Illnesses CBFP Community Based Family Planning CPF Country Partnership Framework CSC Community Steering Committees CSO Civil Society Organization DA Designated Account DGR Direction Générale des Ressources (General Directorate of Resources) DHS Demographic and Health Survey DPSHA Department for the Promotion of Health, Hygiene and Sanitation ECD Early Childhood Development ESMF Environmental and Social Management Framework FAN Foyer d’Apprentissage Nutritionnel (Hearth model) FAO Food and Agriculture Organization FARN Foyer d’Adaptation et de Réhabilitation Nutritionnelle (Positive Deviance/Hearth model approach) FHC Free Health Care FM Financial Management FP Family Planning GASC Groupement d'agents de santé communautaires (Community Health Worker Group) GDP Gross Domestic Product GoB Government of Burundi GRS Grievance Redress Service HCI Human Capital Index HCP Human Capital Project HFBFP Health Facility-based Family Planning HMIS Health Management Information System HSDSP Health Sector Development Support Project HV Home Visit IA Implementing Agencies ICR Implementation Completion Report ICT Information and Communication Technology IDA International Development Association IEY Investing in Early Years IFR Interim Financial Report IMCI Integrated Management of Childhood Illnesses IPF Investment Project Financing IPPF Indigenous Peoples Planning Framework ISR Implementation Status Report ISTEEBU Institut de statistiques et d'études économiques du Burundi (Institute of Statistics and Economic Studies of Burundi) KIRA Health System Support Project PROJECT M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey ML Mamans Lumière (Nutrition community volunteers) MoH Ministry of Health MoU Memorandum of Understanding MSC Multisectoral Steering Committee MTC Multisectoral Technical Committee MWMP Medical Waste Management Plan NGO Non-governmental Organizations NPV Net Present Value OP Operational Policy PBF Performance-Based Financing PDO Project Development Objective PEFA Public Expenditure and Financial Accountability PFM Public Financial Management PIM Project Implementation Manual PPC Provincial Project Coordinator PPSD Project Procurement Strategy for Development PTU Project Technical Unit SBC Social and Behavior Change SIEF Strategic Impact Evaluation Fund SUN Scaling Up Nutrition TFR Total Fertility Rate ToRs Terms of Reference TPS Techniciens de Promotion de Santé (Health Promotion Technician) UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children's Fund VP Vice-President / Vice-Presidency WASH Water, Sanitation and Hygiene WB World Bank WBG World Bank Group WFP World Food Program WHO World Health Organization The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) TABLE OF CONTENTS DATASHEET ........................................................................................................................... 1 I. STRATEGIC CONTEXT ...................................................................................................... 6 A. Country Context................................................................................................................................ 6 B. Sectoral and Institutional Context .................................................................................................... 7 C. Relevance to Higher Level Objectives............................................................................................. 12 II. PROJECT DESCRIPTION.................................................................................................. 14 A. Project Development Objective ..................................................................................................... 14 B. Project Components ....................................................................................................................... 14 C. Project Beneficiaries ....................................................................................................................... 24 D. Results Chain .................................................................................................................................. 25 E. Rationale for World Bank Involvement and Role of Partners......................................................... 27 F. Lessons Learned and Reflected in the Project Design .................................................................... 28 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 30 A. Institutional and Implementation Arrangements .......................................................................... 30 B. Results Monitoring and Evaluation Arrangements......................................................................... 32 C. Sustainability................................................................................................................................... 34 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 35 A. Technical, Economic and Financial Analysis ................................................................................... 35 B. Fiduciary.......................................................................................................................................... 39 C. Environmental and social Safeguards ............................................................................................. 41 V. KEY RISKS ..................................................................................................................... 42 VI. RESULTS FRAMEWORK AND MONITORING ................................................................... 45 ANNEX 1: Implementation Arrangements and Support Plan .......................................... 51 ANNEX 2: Community Level Approach: Continuum of Services ...................................... 59 ANNEX 3: Description of Community Nutrition interventions Focusing on the first 1,000 Days ............................................................................................................................. 61 ANNEX 4: Intervention Framework for Family Planning Interventions ........................... 64 ANNEX 5: Roles and Responsibilities for Project Implementation .................................. 65 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Burundi Investing in Early Years and Fertility in Burundi (NKURIZA) Project ID Financing Instrument Environmental Assessment Category Investment Project P165253 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 05-Sep-2019 30-Jun-2024 Bank/IFC Collaboration No Proposed Development Objective(s) Increase the coverage of community based nutrition interventions among women of reproductive age and children under two and to increase utilization of family planning services in targeted areas Components Component Name Cost (US$, millions) Page 1 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Community interventions to increase coverage of nutrition services and utilization of 23.70 family planning services Strengthening institutions, leadership and monitoring 6.30 Contingency Emergency Response Component (CERC) 0.00 Organizations Borrower: Republic of Burundi Implementing Agency: Ministry of Public Health and Fight against AIDS PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 30.00 Total Financing 30.00 of which IBRD/IDA 30.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 30.00 IDA Grant 30.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount National PBA 0.00 30.00 0.00 30.00 Total 0.00 30.00 0.00 30.00 Expected Disbursements (in US$, Millions) WB Fiscal Year 2020 2021 2022 2023 2024 Annual 1.00 8.00 8.00 8.00 5.00 Page 2 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Cumulative 1.00 9.00 17.00 25.00 30.00 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Agriculture and Food, Education, Social Protection & Jobs 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 ⚫ High 2. Macroeconomic ⚫ High 3. Sector Strategies and Policies ⚫ Substantial 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 ⚫ Substantial 9. Other ⚫ High Page 3 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 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 Sections and Description Schedule 2 – Section I.C. The Recipient shall not later than sixty (60) days after the Effective Date, ensure that the Ministry of Health and each Line Ministry have executed a memorandum of understanding, in form and substance satisfactory to the Association.All such Memoranda of Understanding shall establish the basis for coordination and cooperation among the respective Line Ministries during Project implementation. Page 4 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Sections and Description Schedule 2 – Section I.D.1. Not later than May 31 in each Fiscal Year (or one month after the Effective Date for the first year of Project implementation), the Recipient shall prepare and furnish to the Association a draft annual work plan and budget for the Project (including Training and Operating Costs) for the subsequent fiscal year of Project implementation, of such scope and detail as the Association shall have reasonably requested. Sections and Description Schedule 2 – Section IV.1 The recipient shall not later than three (3) months after the Effective Date or at a later date agreed upon with the Association, (a) update the Project’s finance and administration manual; (b) recruit an internal auditor, with qualifications and terms of reference acceptable to the Association; (c) recruit an additional accountant, with qualifications and terms of reference acceptable to the Association; and (d) update the terms of reference of the Project’s financial management specialist. Sections and Description Schedule 2 – Section IV.2. The recipient shall not later than six (6) months after the Effective Date or at a later date agreed upon with the Association, recruit an external auditor, according to terms of reference satisfactory to the Association and in accordance with the Procurement Regulations. Conditions Type Description Effectiveness Effectiveness: Article IV – 4.01. The Recipient has prepared and adopted the Project Implementation Manual, in form and substance satisfactory to the Association. Page 5 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) I. STRATEGIC CONTEXT A. Country Context 1. Burundi’s decade of civil war and its long period of recurring political insecurity have resulted in stagnant economic development, increased poverty, displacement of the local populations, and destruction of existing infrastructure. Progress in the peace process and the 2000 signing of the Arusha Peace Accords ushered in a period of fragile political stability. After two years of contraction in 2015 and 2016, Burundi’s economy returned to low but positive real growth in 2017, expanding by an estimated 0.5 percent (World Bank). The suspension of external budget support precipitated by the 2015 election crisis led to fiscal consolidation and increasing reliance on the Central Bank to finance the Government deficit. Foreign exchange shortages remain acute, leading to Government policies to ration supplies. Growth is projected to recover over the medium term, but the economy will remain at a low-level equilibrium. Real Gross Domestic Product (GDP) growth for 2018-2019 is projected at 1.5 to 2.5 percent1,2. 2. Poverty, food insecurity and land scarcity are major factors of fragility for the population. Burundi has a total population of 11.4 million, predominantly rural (88 percent). Its GDP of US$218 per capita (constant 2010 US$) makes it one of the poorest countries in the world: close to three out of four Burundians are poor3 and 3.6 million Burundians are in extreme poverty.4 Burundi ranks 185 out of 189 countries in the 2017 Human Development Index. Burundi has the second highest population density in Sub-Saharan Africa (410 inhabitants/ km²) 5 and structural problems of low access to land, loss of soil fertility, low yields, poor quality of production and food consumption, underlie the food stress recorded for almost 45 percent of the rural population.6 3. Burundi’s development prospects are jeopardized by an alarming prevalence of stunting7 countrywide which results in a low Human Capital Index (HCI). Burundi has the second highest prevalence of stunting in the world (56 percent in 2016/2017), which remained virtually unchanged over the last decade. Stunting affects at least one in two children in all provinces of the country except for the capital city (Figure 1). Stunting increases susceptibility to diseases and infections and results in cognitive delays in children, compromised learning, and losses in work productivity. As Burundi decided to be an early adopter of the Human Capital Project (HCP), addressing stunting is high on the country’s development agenda. 4. Population growth constitutes a major challenge for the country’s economic development and further aggravates the stunting challenge. Based on current trends, with a population growth rate of 3.1 percent, Burundi’s population is expected to double every 21 years, resulting in 25 million additional children stunted by 2050. In Burundi, fertility and stunting are intertwined given the effect of short birth spacing on stunting, high population pressure on household consumption and allocation as well as on government 1 World Bank (2018) Macroeconomics, Trade and Investment Global Practice. 2 According to the Institut de statistiques et d'études économiques du Burundi (ISTEEBU), real GDP growth was 3.6 percent in 2017 and between 3.8 and 4.1 percent in 2018-19. 3 72.9 percent live with less than US$1.9 per day. 4 World Bank (2016). Burundi Poverty Assessment. 5 https://data.worldbank.org/indicator/EN.POP.DNST?locations=BI. 6 IPC in Burundi; ipcinfo.org. 7 Stunting is defined as the percentage of children, aged 0 to 59 months, whose height for age is below minus two standard deviations (moderate and severe stunting) and minus three standard deviations (severe stunting) from the median of the WHO Child Growth Standards. Page 6 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) spending on social services. The total fertility rate (TFR) of 5.5 children per women in 2016/2017, a slight decrease compared to the 2010 level, is higher than the sub-Saharan Africa average (4.8 in 2016). Burundi’s population is very young, with those under the age of 19 making up 55 percent of the population.8 High fertility limits girls’ education, and hence their workforce participation, leaving most women in the informal sector in lower productivity, wage, and low-skilled jobs that do not help realize the demographic dividend. B. Sectoral and Institutional Context 5. Causes of stunting are multisectoral in Burundi. Fetal growth restriction and preterm birth are the first cause of stunting in the country, followed by limited access to clean water sources, poor sanitation and personal hygiene as well as mother and child feeding and care practices (Figure 2).9 Bivariate analysis on factors associated with fetal growth restriction and preterm birth in Burundi, using the 2016-2017 Demographic and Health Survey (DHS) data shows that, children from poorer women and from women with lower level of instruction are more at risk. Furthermore, the age of the mother, her nutritional status, the number of siblings and the number of antenatal care visits are also associated with fetal growth restrictions and preterm birth. High fertility rates, inadequate infant and child practices, and increasing strain on natural resources hinder the ability to meet the nutritional needs of children. Childhood stunting rises with birth order: among the poorest households, stunting rates increase from 59 percent for the first birth to 68 percent for the third birth. There is also an inter-generational cycle of malnutrition: stunted mothers are more likely to have stunted babies; young mothers under 20 are also more likely to have low-birth weight babies (14 percent in 2010) compared to mothers aged 20-34 (10 percent) as per the DHS data. 6. Ensuring adequate food intake in Burundi for the most vulnerable groups (children under five, pregnant and lactating women) is challenging given prevailing barriers to access the seven recommended food groups. A 2017 survey, conducted by the International Institute of Tropical Agriculture in six Burundian provinces affected by stunting, showed that 70 percent of the population had access to less than four food groups out of the seven recommended. It showed the high per capita consumption of staple foods (roots, tubers and cereals) and low level of consumption of animal and plant proteins. As in most of the sub-Saharan countries where the low level of food diversification is part of the underlying causes of malnutrition, pro- nutrition interventions by the agricultural and livestock sectors are needed to enhance access to high nutritional value foods and effectively contribute to the fight against malnutrition. 7. Poor access to Water, Sanitation and Hygiene (WASH) services and inappropriate household practices hamper progress in reducing malnutrition in Burundi. In 2015, 48 percent of the rural population had no access to “at least basic water” and 49 percent had no access to “at least basic sanitation”.10 Inadequate WASH practices can lead to cases of diarrhea, which cause significant fluid loss and undernutrition that can lead to death. In Burundi, almost a quarter of children under 5 years had at least an episode of diarrhea during the two weeks before the 2016/2017 DHS survey; only 44 percent of those children received adequate food and 30 percent received an adequate amount of liquid. 8http://hdr.undp.org/en/countries/profiles/BDI 9 Danaei, G., Andrews, K. G., Sudfeld, C. R., Fink, G., McCoy, D. C., Peet, E., ... & Fawzi, W. W. (2016). Risk factors for childhood stunting in 137 developing countries: a comparative risk assessment analysis at global, regional, and country levels. PLoS medicine, 13(11), e1002164. 10 https://washwatch.org/en/countries/burundi/summary/statistics/ Page 7 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Figure 1: Stunting prevalence by province (2016-2017) Figure 2: Stunting cases among two-year old attributable to individual risk factors in Burundi (2010) Fetal growth restriction and 77.5 preterm birth Water, sanitation and 56.6 biomass fuel use Child nutrition and infection 42.4 Maternal nutrition and 31.4 infection Teenage motherhood and 3.8 short birth intervals 0 20 40 60 80 100 Attributable stunting cases (thousands) Source: Burundi case study for Danaei, et al. (2016). Risk factors for childhood stunting in 137 Source: DHS 2016/2017 developing countries: a comparative risk assessment analysis at global, regional, and country levels. 8. Burundian women face multiple and mutually reinforcing constraints on women’s agency, which directly or indirectly affect their childbearing patterns and ability to ensure survival of their children. Women have limited economic opportunities and low control over domestic resources within the household. Women who report participating in three or more household decisions in Burundi are more likely to use Family Planning (FP) than those who do not. Higher level of education of mothers is also associated with greater autonomy, delayed marriage, lower demand for children, and improved child health.11 The prevalence of girls between 15-19 years of age being mothers or pregnant with their first child remains low relative to regional peers at 8.3 percent. Early birth increases risks of delivery complications and low birth weight (thus increasing the risk of a child being stunted); it also limits prospects for further education or for engaging in high value employment. 9. High levels of childbearing in Burundi stem primarily from high rates of marital fertility and low levels of contraceptive use. Modern contraceptive prevalence increased only from 18 to 23 percent between 2010 and 2016-2017. Stated ideal family size declined from 5.3 in 1987 to 4.2 in 2010, with virtually a one child difference between ideal family size of the poorest in comparison to the best off households.12 Wanted fertility and ideal family size lower than the total fertility rate imply the existence of latent demand for FP. Unmet need for FP in Burundi varies according to the level of education (32.5 percent for women with no education against 20.2 percent for women with secondary education) and wealth status (30.8 percent in the 11 World Bank (2018). Demographic Challenges and Opportunities in Burundi. Washington, D.C.: World Bank Publications. 12 Ibid. Page 8 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) poorest quintile against 25.4 in the richest). Furthermore, Burundi is characterized by a very high discontinuation rate13 of 40 percent. Side effects and desire to get pregnant are the main reasons (33 percent and 31 percent respectively). 10. Both demand and supply constraints hamper a significant change in FP trends in Burundi. The national Plan for the acceleration of FP (2015-2020) 14 identified four challenges to demand for FP services and supportive environment: (i) low demand for contraceptive methods by the population in general and by women in particular; (ii) low involvement of men in FP; (iii) low demand for information and FP services by adolescents and young people; and (iv) low commitment of community leaders in promotion of FP. The plan also reported four challenges in FP provision: (i) inequitable geographical access to FP services; (ii) low quality of FP service provision; (iii) low access for adolescents and young people to services adapted to their needs; and (iv) inadequate provision of FP services by the private sector and faith-based health facilities. 11. The national introduction of free health care (FHC) for maternal and child health services and performance-based financing (PBF) resulted in considerable improvements in access to care but the health Millennium Development Goals were not achieved. Institutional deliveries increased drastically from 31.8 percent in 2005 to 85 percent in 2016-2017.15 Mortality nevertheless remains high, due to high fertility16 and poor quality of care. Under-five mortality was estimated at 78/1000 livebirths and the maternal mortality ratio at 334/100,000 livebirths in the 2016-2017 DHS (Table 1). 12. Key indicators for early childhood development (ECD), which are related to households’ behavior and practices, are lagging behind and are not experiencing progress. Only 10 percent of children six-23 months consume a minimum adequate diet in 2016-2017 compared to 9 percent in 2010; only 5 percent of households use soap for handwashing and a large majority of households have no access to improved latrines. Early stimulation programs for children under three are not supported by the Government of Burundi (GoB) and early learning programs for children aged three-six years old are only accessible to 12.6 percent of the target population (Table 1). Table 1: Trends in Key ECD Indicators in Burundi INDICATORS 2005 2010 2016-17 Health Status Infant Mortality Rate (per 1,000 live births) 59 47 Under-five Mortality Rate (per 1,000 live births) 96 78 Maternal Mortality Ratio (per 100,000 live births) 620 500 334 Total Fertility Rate (children/women) 6.7 6.4 5.5 Adolescent pregnancy (%) 7 8.3 Anemia (% of children under 5) 59.2 45 61 Stunting (% of children under 5) 61.7 58 56 Essential health services % married women using modern contraceptives 7.9 18 23 13 Discontinuation rate is defined as starting contraceptive use and then stopping for any reason while still at risk of an unintended pregnancy. 14http://www.familyplanning2020.org/sites/default/files/PlandactionPF_Burundi_Final.compressed_0.pdf 15MICS 2005 and DHS 2016-2017. 16FP is the primary prevention of maternal mortality as the fewer women are pregnant, the less risk of dying in pregnancy and childbirth; risks of delivery complications are also greater with short birth spacing and early pregnancy. Page 9 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) INDICATORS 2005 2010 2016-17 % of unmet demand for FP 31 30 % of assisted deliveries in a health facility 31.8 63.1 81 % of women who receive at least 4 antenatal care visits 33.4 49 % of women age 15-49 who are anemic 33.4 19 39.3 % of children born with low birth weight 11.2 12.9 29 % of children 6-59 months receiving vitamin A 7 81 80.7 supplementation Feeding/Care Behaviors % of children 0-5 months exclusively breastfed 44.7 69 83 % of households consuming adequately iodized salt 98 85.9 96.1 % of children 6-23 months consuming a minimum acceptable 9 10 diet % households sleeping under Long Lasting ITN 52 46 % children fully vaccinated 83 85 Education Number of pre-primary teachers 318 2536 Female secondary school gross enrollment rate (lower and 10.7 18.7 40.5 upper secondary enrolment of respective population) Pupils-Pre-Primary Teacher Ratio 1:28 1:34 1:34 % of children enrolled in at least one year of pre-primary 1.7 10.2 12.6 education (Gross Enrolment Rate) Water, Sanitation and Hygiene % of households with access to improved water sources 76 82.8 % of households washing hands with soap and water 5 5 % of households using improved latrines 31 39 Social protection Birth registration (% of children under 5) 60 75.2 Source: Multiple Indicator Cluster Survey (MICS) 2005 and demographic and Health Surveys 2010 and 2016- 2017. 13. Policy documents on nutrition and population growth reflect the GoB’s commitment to tackle stunting and fertility. The Government Declaration on a National Demographic Policy sets the ambitious goal of lowering fertility rate to three children per women and population growth rate to 2 percent by 2025 (2011). Other key documents related to demography include the Burundi Vision 2025, which recognizes that addressing demographic issues are central to Burundi’s development (2011); the two Gitega Declarations from religious leaders (2010 and 2017)17; and the Roadmap for seizing the demographic dividend by investing in the youth (2017). The Burundi Multisectoral Platform for Food Security and Nutrition as part of the multisector Scaling Up Nutrition (SUN) movement was launched in 2013 leading to the 2014-2018 National Strategic Plan for Nutrition and Food Security which focuses on political commitment for nutrition of young children, micronutrient supplementation, food fortification, and increased integration of nutrition interventions in primary health care and local communities.18 The second phase plan, for implementation in 2019, is under development. Nevertheless, lack of financial resources and of a sound monitoring and 17 https://burundi.unfpa.org/en/node/30061 18 The National Health Policy (2016-2025) also lists malnutrition, maternal and child health as key priorities. Page 10 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) evaluation (M&E) framework to accompany these policies resulted in slower than expected progress in the implementation of these policies and strategies. 14. The Project aims to address the lacunas of the prevailing service delivery response and platforms through creation of a community platform. At the facility level, there is a shortage of qualified health workers below World Health Organization (WHO) recommended densities and a geographic divide with qualified staff being concentrated in the capital city.19 At the community level, the health sector benefits from the most structured platform to deliver services which will be a strong asset for proposed interventions: the Community Health Strategy (2012) led to the recruitment of 12,000 voluntary community health workers (CHW) nationwide grouped in associations that report to public health centers (Groupement d'agents de santé communautaires (Community Health Workers Group) or GASC). As other community level actors, CHW are volunteers; although there is no plan to integrate them in the civil service, the GoB’s strategy is to gradually include them in the results-based financing program whereby GASC receive financial incentives. The package of services delivered by CHW includes some nutrition (mainly detection and referral of acute malnutrition cases) and FP services but the community health approach is hampered by several weaknesses including: (i) weak integration of CHWs into the health system; (ii) insufficient supervision; (iii) insufficient harmonization of CHW training and training tools; and (iv) community information system at its early infancy.20 The workload of CHW does not allow them to provide a comprehensive package of quality services: In Burundi, even relatively small communities have target populations that make it difficult for one volunteer CHW to realistically conduct monthly household visitation, especially as nearly 20 percent of the population is under five years of age.21 15. Other community level actors operate in Burundi, but with limited resources and in a less coordinated manner. The Health Promotion Technicians are responsible for WASH activities; they are employed by health centers and report to the Ministry in charge of health as well as coordinate activities led by the Ministry in charge of water and sanitation in rural areas. In addition, a form of Positive Deviance/Hearth model22 has been tested by United Nations (UN) agencies and international non- governmental organizations (NGOs) in some parts of the country and are now becoming a Government strategy: Community Nutrition volunteers called “Mamans Lumière” (ML) teach mothers how to combine foods that they already have in their kitchens and sensitize them on good food and nutritional practices, thus become reference persons for all matters relating to food, hygiene and childcare.23 The GoB is currently reviewing options to provide incentives to voluntary ML, through the community PBF program. Community platforms dealing with child protection, social protection or agriculture are less developed: they are either non-existent or limited in scope and scale (Table 2). 19There was a total of 18, 570 healthcare personnel in 2016: 3 percent doctors, 37 percent nurses, 0.4 percent midwives, and 40 percent being unskilled support staff. 18 percent of health workers and 36 percent of all doctors reside in the capital city. 20 Fergulio, N., and Handley, G. (2017). Burundi: Delivering Health Services Under Fiscal Stress. Public Expenditure Review. Washington, D.C.: WBG Publications. 21 Weiss, J., Makonnen, R., & Sula, D. (2015). Shifting management of a community volunteer system for improved child health outcomes: results from an operations research study in Burundi. BMC health services research, 15(1), S2. 22 This process identifies affordable, acceptable, effective and sustainable practices that are already used by at-risk people and do not conflict with the local culture. 23 http://www.nursinglibrary.org/vhl/bitstream/10755/616176/1/2_Chaponniere_P_p79359_1.pdf Page 11 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Table 2: Overview of the Main Community-based Actors Involved in Nutrition and FP in Burundi Community Target group Geographical Intervention Payment/incentives actors coverage Community Women of National Integrated management CHW are volunteers. Per Health workers reproductive age, coverage of childhood illnesses at government’s policy, and (organized in pregnant and community level, depending on resource Grouping of lactating women, distribution of availability, they will gradually Community children under 5 contraceptives, receive incentives through Health Workers and households prevention, behavior community PBF. or GASC) change (including nutrition) Mamans Mothers and Scattered Positive Deviance/Hearth The Government is planning Lumières (ML) children with coverage, process whereby Mamans to integrate the ML in the moderate acute depending on Lumière deliver nutrition Community PBF scheme; ML malnutrition donors’ support specific and sensitive would receive incentives interventions through secondary contracts for nutrition indicators). Health Promotion Women of National (staff WASH at community level TPS are employed by Ministry Technician reproductive age, of health Some are trained to of Health (MoH) and on (Techniciens de pregnant & center) deliver injectable Government’s payroll. Promotion de lactating women, contraceptives. Santé or TPS) children under 5 Supervise work of CHW and households Rural agronomist Farmers National Agriculture and animal Employed by Ministry in (rural extension raising at local level. charge of Agriculture and on workers) Government’s payroll. C. Relevance to Higher Level Objectives 16. The Project is aligned to the Government’s priorities set out in the National Development Plan 2018-2027. The second strategic orientation on “Developing Human Capital” recognizes health, nutrition, education, social protection, job opportunities for the youth and the demographic dividend as principal axes for intervention. The project also contributes to the first strategic orientation related to “Agriculture, animal husbandry and food security”. 17. Reducing malnutrition and addressing high fertility are central to the World Bank Group (WBG) agenda. At the global level, the Project relates to the WBG’s initiative on Investing in the Early Years (IEY) which aims to reduce childhood undernutrition, ensure children receive early stimulation and learning; and protect vulnerable children; and to the HCP which aims to enhance investment in people through nutrition, health care, quality education, jobs and skills to help build human capital, a key to ending extreme poverty and creating more inclusive societies. At the country level, nutrition and fertility are central to the Country Partnership Framework (CPF) FY 19-23 (Report No. 122878-BI) as improving nutrition and reducing fertility can help build resilience and foster peace. Nutrition and fertility related interventions contribute to mitigate the impact of humanitarian crisis and offer social interventions to build resilience. The CPF puts emphasis on services to tackle fertility and stunting, maximizing the 1000 days window of opportunity for cognitive development in infants and its effect on future productivity. Page 12 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 18. The Project will help Burundi, an Figure 3: World Bank Projects Supporting the Nutrition or Fertility Agenda early adopter of the HCP, to take bold actions to increase investments in its human capital. In 2018, the HCI of Burundi was 0.38 suggesting that a child born in Burundi today will be 38 percent as productive when he/she grows up as he/she could be if she enjoyed complete education and full health. This HCI calls for raising awareness and increasing interventions to build human capital. The new approach put forward by the Nkuriza Project will be central to the implementation of the HCP in Burundi. Efforts to improve human capital investments through the Nkuriza Project will be complemented by other World Bank funded projects (Figure 3). The Nkuriza Project will leverage the Health System Support Project (KIRA- P156012) in all six Project provinces to strengthen the supply and quality of facility based reproductive health services; this will aim to match increased demand generated by Nkuriza in communities. KIRA and Nkuriza will also develop synergies for increased effectiveness of services delivered by CHWs. In Kirundo, the Social Protection project (Meranbakandi)24, which identifies vulnerable households with young children and provides them with cash transfers, will be able to leverage the community platform set up by Nkuriza to provide these households with a comprehensive package of accompanying services to help them adopt adequate behaviors for healthier children and improved child environment. Agriculture projects funded by the World Bank25, which are present in all six Project provinces, will also come in support to the nutrition and human capital agendas by putting more emphasis on production of nutritious food for local utilization. They will contribute to address demand stimulated through the Nkuriza Project; in turn, agriculture projects will also benefit from the targeting mechanism of Nkuriza to identify the most vulnerable households with young children and make sure they benefit from the nutrition sensitive interventions they are supporting. Finally, the Education 24 Burundi Social Safety Nets Project - P151835. 25 Agro-Pastoral Productivity and Markets Development Project – P107343; Great Lakes Regional Integrated Agriculture Development Project – P161781. Page 13 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) project26, which supports a school feeding program in Kirundo, will ensure the continuum of care for children of school age to ensure their learning capacities are maximized. Taken together, this multisectoral and coordinated approach will contribute to address human capital challenges in the country. II. PROJECT DESCRIPTION A. Project Development Objective PDO Statement 19. The proposed Project Development Objective (PDO) is to increase the coverage of community based nutrition interventions among women of reproductive age and children under-two, and to increase the utilization of family planning services in targeted areas. 20. The persistence of high fertility and stunting in Burundi calls for a change in approaches to address these issues. As facility-based and community-based services delivered so far have not been able to significantly curb the fertility and malnutrition situation in the country, the Project will support the GoB in defining a new model to tackle these issues in a more integrated way. The Project adopts a multi-sectoral approach, involving sexual and reproductive health, nutrition-specific27 as well as nutrition-sensitive28 interventions to accelerate improvements in nutritional status of mothers and children and ensure optimal child development.29 It uses a life-cycle approach whereby interventions are focused on target populations, through a combination of horizontal and vertical service delivery approaches to increase efficiency and sustainability of interventions. The proposed horizontal approach, at community level, will ensure a continuum of services for adolescents/women of reproductive age, pregnant and lactating women, children under five and households/couples (Annex 2). B. Project Components 21. Following other countries that have substantially reduced stunting and curbed fertility, this Project is designed to set up the community platforms required to deliver FP and nutrition services to communities, starting in the 6 provinces that have the highest stunting and fertility rates in the country. The project adopts a learning approach to define a model and test its effectiveness in reaching women and children under two with nutrition and FP services. Lessons learned from the implementation of this Project will inform the definition of a national model of multisectoral community platforms. Expanding this national model to the remaining 12 provinces of the country would provide the entry point for all GoB and development partners’ interventions at community level. The Nkuriza Project aims to support the GoB in 26 Burundi Early Grade Learning Project – P161600. 27 Nutrition-specific interventions address the immediate causes of undernutrition, like inadequate dietary intake and some of the underlying causes like feeding practices and access to food. 28 Nutrition-sensitive interventions can address some of the underlying and basic causes of malnutrition by incorporating nutrition goals and actions from a wide range of sectors. They can also serve as delivery platforms for nutrition-specific interventions. Key findings from the 2013 Lancet Series on Maternal and Child Nutrition show that nutrition-sensitive programs in agriculture, social welfare, early child development, and schooling can be successful at addressing several underlying determinants of nutrition. 29 Children under-two with simultaneous access to one (37 percent of children), two (36 percent), or all three (11 percent) underlying factors of nutrition in Burundi (i.e., adequate food/care, health and WASH) are less likely to be stunted by 11 percent, 22 percent and 31 percent respectively, compared to those with no access to these three factors (22 percent). Source: Skoufias 2018. All Hands-on deck: Reducing stunting through a multisectoral approach in SSA and Burundi. World Bank. Page 14 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) designing and implementing a new approach which aims to reach 30 percent of children and 50 percent of women with essential nutrition and FP services by 2023 in six provinces. A gradual scale-up approach, depending on available funding and alignment of actors around the GoB’s strategy, would result in significant progress in stunting and fertility reduction in the medium to long term, as observed in other countries that have set up such platforms (e.g. Senegal). 22. The Project relies on two drivers of change: community platforms to deliver services and integrated social and behavior change communication (BCC). Currently the lack of platform at community level is a critical binding constraint for the success of interventions to address stunting and aimed at changing behavior and practices at household level. The Project will thus support the creation of multisectoral platforms where services will be provided by community stakeholders. Monthly growth promotion events organized in communities to weigh children under two will be an entry point for delivering services to mothers and children, such as reproductive health, nutrition services and engaging communities for social and behavior change through a harmonized communication strategy. The Project will use innovative approaches to monitor and create awareness of linear growth building on similar work in other countries (e.g. Rwanda). All sectors (e.g. social protection, education, agriculture) will benefit from the existence of these platforms and could use them for activities targeted to mothers, children and households at large. The community anchor will also facilitate acceptability and sustainability of the approach. The Project will also support the health system to match demand for services created through the Project in communities with adequate supply of services in primary health care facilities. Capacity and institutional strengthening will underpin the Project to ensure adequate project implementation, quality of services and ownership of the approach in the perspective of its scale-up to the remaining provinces. The unprecedented commitment of the GoB to address stunting and fertility issues and to invest in its human capital constitute a positive environment and a major opportunity for the Project. Component 1: Community interventions to increase coverage of nutrition services and utilization of family planning services (US$23.7 million equivalent) 23. Component 1 will be implemented with the support of contracted Implementing Agencies (IAs) at the provincial level. IAs can be NGOs or Associations recruited by the Government with recognized capacities of implementing community-based interventions at a provincial level. The IAs will develop strategies to implement the integrated package of FP and community nutrition interventions based on community involvement and ownership. They will be selected through a competitive approach ensuring contracting with the most qualified and relevant organizations, based on knowledge of local context and expertise in community nutrition and FP services. IAs will be responsible for project implementation and monitoring of Project performance at all levels (community, colline, commune, province)30. IAs will foster community engagement and mobilize community actors for the delivery of integrated services. Through IAs, the Project will fund the delivery of the proposed new package of community level interventions, innovative services at facility level and social and behavior change. The Project will also procure essential inputs for nutrition and FP services in Project areas. 30Burundi is a unitary state which is sub-divided at three levels: provinces, communes, and collines (hills). The largest administrative division in Burundi is the province. There are 18 provinces in Burundi and each province has a Provincial Governor. The second-largest administrative division is the commune (municipality). There are 117 communes in Burundi. The third subdivision in Burundi is the colline (literally "hill") of which there are 2,638 in the country. Finally, the smallest subdivision is the Sous-Colline (sub-hill); there are a total of 8,731 sous-collines in the country. Page 15 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Sub-Component 1.1: Nutrition specific and nutrition sensitive interventions (US$12.8 million) 24. The objective is to improve demand for and utilization of essential services known to improve nutritional status of children under-two by introducing and integrating community-based interventions related to maternal health, nutrition (specific and sensitive) and early stimulation. Proposed interventions build on existing and adapted community-led approaches to develop the demand-side. Community engagement and empowerment will be at the center of the proposed approach to promote utilization of services and adoption of appropriate behaviors for ECD. The existing CHW will be the entry point to expand the community-based service delivery platform with high impact interventions for pregnant and lactating women as well as children under-two. Primary health care facilities will support community-level service delivery through training and supervision of community actors. Nutrition sensitive interventions targeting the most vulnerable and focusing on household food security and access to safe water and sanitation will complement this package to ensure comprehensiveness of the proposed response (See Annex 3 for further details on community nutrition interventions). IAs will also work with agronomy and animal health technicians at commune and community levels, Health Promotion Technicians (TPS), in charge of WASH activities, and social community workers to implement nutrition sensitive activities. 25. The Project will introduce monthly growth monitoring and promotion for children under-two as a new strategy and an entry point for community level activities around nutrition. Building on the FARN (Foyer d’Adaptation et de Réhabilitation Nutritionnelle or Positive Deviance/Hearth approach) experience, community-nutrition sites will be set up to be the convening point for different activities throughout targeted collines. Within community-nutrition sites, ML will be trained to monitor monthly growth of children under- two following the WHO protocol. An adequate weight gain is foreseen each month for children during their first two years of life pushing the ML to conduct interpersonal communication with mothers and caregivers. This dialogue will be the cornerstone for optimizing the child’s growth because of the decisions that will be taken regarding all the different types of caring needed by the child for the next month. From that dialogue, different recommendations can be raised related to feeding practices, hygiene and sanitation, child’s social environment, etc. Growth Promotion of children includes home visits (HV) for children who are absent or who did not have an adequate growth over two consecutive months without being severely malnourished. Children suffering from severe acute malnutrition will be referred to health structures for an adequate medical care. ML will also be trained to reinforce mothers’ and caregivers’ capacities to stimulate children during their first 1,000 days. Promoted care practices for early stimulation will be on simple attitudes during pregnancy, feeding and playing moments that contribute to child development and well-being. Cooking demonstration activities will be organized in nutrition sites and will offer privileged moments of discussion on child feeding, local recipes and feeding community practices. These activities will be implemented with and by the community. A community-based working environment will be built at the colline-level around ML who will deliver services and community steering committees (see paragraph 70) which will support implementation. 26. The Project will support other community maternal and child health services. Children under-two will benefit from micronutrient supplementation activities with Vitamin A and micronutrient powders. ML will promote Community-Integrated Management of Childhood Illnesses (C-IMCI) behaviors emphasizing on exclusive breastfeeding, complementary feeding, food diversification, early treatment of childhood illness (diarrhea, malaria, pneumonia, etc.). ML will promote birth spacing and FP, through counseling and referral to CHWs and health facilities, as nutrition sites offer a good opportunity to reach mothers of children under- Page 16 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) two. Quarterly campaigns for active screening of acute malnutrition will be organized; acute malnutrition cases will be managed at community and health center levels according to national guidelines. The Project will strengthen capacities of community actors and health center staff for community-based management of acute malnutrition to ensure effective management of moderate cases at community level and functioning referral system to health facilities for severe cases. 27. The Project will support community-driven projects to improve households’ environment and food security. Only the most vulnerable households, i.e. poor households with pregnant women or children under five, will benefit from those interventions which are critical to demonstrate good practices and ensure resilience and sustainability of the community level approach to address stunting. Community Driven Development (CDD) approaches will be used by IAs to ensure community engagement and development of adapted grants. The CDD approach will also ensure transparency in targeting the most vulnerable households. The IAs will select vulnerable households using rigorous participatory community-based targeting methods. The IAs will also ensure effective control of grant resources to avoid leakage, elite bias or manipulation. This requirement will induce a gradual implementation of the initiative. The IAs will propose a timeline based on the development of a strong community platform which will reflect the community ownership and engagement for the fight against malnutrition. Implementation of community grants will further require support from local actors (community steering committees, local authorities, beneficiaries). (a) Community nutrition initiatives: Community nutrition initiatives will be defined according to community needs to address the non-diverse food environment of most vulnerable households. Engagement of communities will allow identifying community initiatives which will enhance capacities of vulnerable households in general, and women in particular, to produce, buy and provide adequate food for the household, notably for young children and women. The project will promote initiatives supported by the GoB such as kitchen gardens, small livestock husbandry, use of improved seed varieties and animal races, food conservation and transformation technologies. Given limited resources available and need to focus on initiatives that can yield the most results, the Project will support initiatives that have already been tested, rather than innovations, which are beyond its scope. Further expansion, using the same targeting mechanism to ensure focus on vulnerable households with children under two, will be considered if additional resources for the Project or from another project are made available. (b) Community WASH initiatives: The Project will promote access to safe water and sanitation, and best hygiene practices through soft interventions that support behavior change at the community and household levels. The promotion of hygiene of water sources at the community level will help to prevent diarrhea among children under-five. At the household level, the Project will focus on promoting the use of potable and clean water, supporting the most vulnerable households with latrines, hand washing and water purification kits. It will support the Government’s Ending Open Defecation Strategy as a key objective for behavior change at the community level. Page 17 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Sub-Component 1.2: Family planning and reproductive health services (US$9.0 million) 28. The objective is to address demand side barriers of FP and promote access to reproductive health services to reduce fertility rates in Burundi. Persistent high levels of fertility imply a high rate of population growth and therefore a higher number of stunted children. In turn, high levels of childbearing impede on women’s ability to ensure good nutritional status of their children. The large unmet need for FP, high discontinuation rate and still low contraceptive prevalence suggest quality issues and persistence of demand side barriers, including cultural and social norms, that the Project aims to tackle. As most FP services are currently provided at the health center level, which may be too far from users and not addressing the unmet need of all women of reproductive age, the Project will bring and support innovations that will make services closer to the communities in their village or home and offer alternative approaches for better acceptability and adherence to contraception. The Project will support integration of FP into nutrition community-based activities to ensure all women are provided with equal opportunities in accessing FP services. 29. The Project will provide services through two channels: community-based family planning (CBFP), in an integrated way with nutrition services, and Health facility-based family planning (HFBFP) to provide a comprehensive response on FP in Project areas (Annex 4). CBFP will bring FP information and contraceptive methods to women and men in the communities where they live. CHW, TPS and ML will be key actors to deliver services given their affinity for and understanding of the clients they serve. These actors are known in the community, come from the same or a similar cultural background, and as such, can respond to local societal and cultural norms and customs to ensure community acceptance and ownership as well as provide important insights to address social, cultural and traditional barriers to FP use. While CHWs may represent a threat to confidentiality with respect to SRH and FP in other contexts, the fact that in Burundi most fertility is within marriage makes community level actors an effective delivery mechanism to get FP commodities to the doorstep. HFBFP has been the main channel of FP provision to date, but it did not reach all potential users of FP and did not address unmet need for FP. The Project will test new approaches to increase utilization of FP. Through training, communication, financial incentives, and procurement of essential medicines and contraceptives, the Project will aim to increase the quality of interventions delivered in health facilities. Key interventions such as antenatal care services, postnatal care services, immunization services and post-natal care will be targeted to integrate counselling, education and communication for behavior change as well as provision of FP modern methods. Post-partum services will be a key area of focus to take advantage of the fact that 85 percent of women deliver in health facilities (DHS 2016/17); women delivering in health facilities will be provided with a range of FP methods to guide their choice with support of trained health care providers. Linkages with the FHC/PBF program to incentivize post-partum FP and improve quality of FP services provided will be explored. 30. The Project will support innovations to improve delivery of contraceptives within communities. This approach will rely on IAs, traditional actors (CHWs and Health Promotion Technicians) as well as non- traditional actors, including NGOs and faith-based organizations. (a) Introduction of self-injectable FP: The project will support the scale-up of a new contraceptive method, which is self-injectable (Sayana Press), and does not require women to visit a health center regularly for contraception. These contraceptives will be delivered by community workers as well as available in health facilities and private pharmacies. Page 18 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) (b) SMS alerts: The project will leverage information and communication technology (ICT) for FP and maternal health outreach activities to inform women about FP, as well as alert them in case of risks related to pregnancies or childbirth (Rapid SMS). (c) Hotline on sexual and reproductive health: Hotlines (free of charge) will be set up in project areas; women will be able to call a trained CHW or health care provider for information on FP, advice and referral to the nearest health facility for further support. (d) Auto-administration of pregnancy tests by women assisted by CHW: This innovation aims to improve antenatal care services and women’s health by making sure women are aware of their pregnancy early enough and can be sensitized to visit a health facility during the first trimester of their pregnancy. 31. The Project will procure contraceptives, lifesaving drugs for mothers31 and iron folic acid in project areas. Procurement of contraceptives through UNFPA (United Nations Population Fund) supply chain system will aim to ensure that new products, such as Sayana Press, and other modern contraceptive methods, are available in project areas and to address a potential funding gap for modern contraceptives. The project will procure iron and folic acid for pregnant women through UNICEF (United Nations Children's Fund) for health facilities in project areas and support community level interventions to sensitize women on iron and folic acid supplementation during pregnancy. 32. The Project will strengthen the procurement and supply chain and logistics management system for contraceptives. The use of smartphones, already tested by MoH with support from UNFPA, will be scaled- up in Project areas for FP stock management. The use of smartphones will improve stock management in facilities and supply to communities by providing accurate information on availability of FP commodities. Information will be shared by community and facilities to districts and provinces. Implementing agencies will be responsible for ensuring smartphone ICT technology is rolled out in all Project areas. Capacities will be strengthened to avoid stock outs which hamper the quality of services; consumption forecasts will be done on a quarterly basis, including assessment of availability and quality of FP commodities. 33. The Project will sensitize on practices and services that can reduce maternal and infant mortality, which in turn will facilitate uptake of FP. Interventions supported by the Project will include: (i) promotion of antenatal care visits (early during the first trimester) and four antenatal care visits, as well encouraging men’s participation; (ii) postnatal care and promotion of deliveries in health facilities; and (iii) adaptation of sexual and reproductive health behavior change messages to the Batwa population. 34. The Project will foster dialogue and collaboration with the Catholic Church and its network of faith- based health centers. Strong advocacy will be conducted with religious leaders through workshops to address FP barriers and ensure they are able to commit and engage in community promotion of birth spacing and maternal and child health and nutrition. The Project will support faith-based health facilities to provide FP services. While health workers in these facilities do not deliver modern contraceptive services, the Project will engage progressively with these facilities. Health providers will be trained to deliver improved counseling on the benefits of birth spacing, on natural FP methods as well as on referral of patients to Government’s health facilities if they want to use modern contraceptive methods. The Project will support procurement of cycle beads to faith-based facilities in Project areas to improve quality of services provided and create a collaborative environment in exchange of informing patients about available options for FP (modern and 31 http://www.who.int/medicines/publications/A4prioritymedicines.pdf?ua=1 Page 19 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) natural) and allowing them to opt for the contraceptive method they choose. Sub-Component 1.3: Social and behavior change communication activities (US$1.9 million) 35. Social and behavior change (SBC) communication is central to the success of community level interventions supported by the Project. SBC activities will aim to change people’s behaviors through educating the community on benefits of birth spacing, as well as on good nutrition practices for mothers and children to prevent stunting and ensure healthy growth of children. Community members will be mobilized around the community delivery platform supported by the Project. Furthermore, community initiatives supported by the Project will be accompanied by enhanced SBC communication around nutrition and fertility. Strategic approaches for engaging religious leaders in FP communication will aim to bring them to commit and engage in promotion of FP and good nutrition practices. The Project will make sure that religious leaders are involved in planning and implementation of community-based activities. 36. A revamped SBC communication strategy will be developed as part of the broader communication strategy supported by the Project (see Component 2). The SBC strategy will integrate FP and nutrition SBC messages and ensure they are promoted using the same channels (health centers, nutrition sites, FARN), by the same actors and in common platforms. Communication and social mobilization activities will focus on birth spacing and community practices that promote health and nutrition of children and pregnant women, disease-preventive measures, and home-based care and care-seeking for sick children. SBC messages will also encourage men and intra-spousal communication on ideal family size and contraceptive use and targeted BCC activities for adolescent girls and boys related to FP and parenthood. It is expected that communication tools developed with support from the Project will be used by other World Bank projects and projects supported by other development partners to harmonize SBC messages. The Project will support the use of different channels of communication for increased outreach and impact such as SMS, radio, TV shows, events in communities, etc. 37. This integrated SBC communication strategy will address nutrition and fertility challenges in a more comprehensive and efficient way to cultivate communities’ awareness and mobilize them for mothers and children’s health. SBC communication activities are central to the Project as the needed energy and strength to bring change must come from the various members of the communities. SBC will empower communities, women especially, with increased knowledge, leadership, and less barriers to access to FP and nutrition services and to adopt the key behaviors for the community development. 38. Delivering SBC communication will involve existing as well as new actors. IAs will bring innovation and support traditional actors, such as CHWs, MLs, nurses, teachers, agriculture relays, etc. to deliver SBC services. The Project will therefore strengthen capacities of community workers for interpersonal and group communication, negotiation, social mobilization and advocacy. Regular reviews of proposed implementation approaches will allow development of corrective actions to ensure greater impact. 39. Adolescent boys and girls will benefit from tailored SBC on nutrition, FP and reproductive health services. The Project will ensure youth and youth associations are engaged in SBC activities to drive social and behavior change on nutrition and reproductive health. The Project will support innovative outreach strategies that can reach more vulnerable adolescents who are usually not reached by institutions. Page 20 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Component 2: Strengthening institutions, leadership and monitoring (US$6.3 million equivalent) 40. This component aims to enhance national capacities for stewardship and coordination of strategies, policies, programs and projects related to nutrition and demographic issues; to support the development and implementation of a strong communication strategy and promote stronger leadership on nutrition and demographic issues; to build and strengthen capacities to implement the Project and the Government’s strategies related to nutrition and demography; and to ensure adequate resources and means for project management. Expenses related to this component include technical assistance, consultants, workshops, formal trainings, on the job trainings, and operational costs. Equipment required for staff recruited by the Project and involved in Project implementation at the central and provincial level (e.g. IT, cars, utilities) will also be included. Sub-component 2.1: Strengthening institutions and capacities (US$3.9 million) 41. Four main areas will be supported through this sub-component to strengthen the Government’s stewardship, leadership and coordination functions: (i) governance structure and management of nutrition; (ii) capacity building; (iii) communication; and (iv) building evidence. 42. Governance structure and management of nutrition: The Project aims to strengthen the national multisectoral nutrition platform (SUN platform) at the central level. In the six provinces targeted by the Project, it also plans to support the SUN in implementing its action plan which aims to decentralize the governance and management of nutrition. Expenditures related to this activity will cover: (i) technical assistance; (ii) capacity building; (iii) operational costs; (iv) meeting costs; and (v) travel and subsistence costs. The Project will support the operationalization of the Permanent executive secretariat of the national platform for food security and nutrition. The structure will be composed of high-ranking civil servants from line ministries involved in the SUN platform and serve as an advisory body to the SUN focal point, providing technical advice and strategic direction on nutrition related topics for the country as well as overseeing nutrition projects and programs implemented countrywide to ensure strategic alignment, harmonization of approaches and synergies between projects and programs. Along with other development partners supporting the SUN secretariat, the Project will support the sustainable structure in developing the necessary tools and expertise to plan, monitor and report on progress in the implementation of the Government’s strategies, programs and projects related to nutrition and food security. The Project will provide resources for capacity building and learning experiences, technical assistance and operational support. 43. Capacity building: Capacity building will be critical to ensure appropriate Project implementation and that adequate capacities for planning, implementation, monitoring and supervision are available. Expenditures will include technical assistance, international training, local training, on the job-training, study tours and operating costs. The Project will support the following interventions and activities: (a) Masters level trainings of freshly graduated students: The Project will finance several 1-year masters level programs in nutrition, reproductive health and environmental health to support the creation of a minimum pool of actors able to deliver activities required to address the stunting and fertility issues in the country. (b) Capacity building of central level Government staff: The Project will finance on the job training for Government’s staff involved in Project implementation to enhance technical capacities to plan, Page 21 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) implement, monitor and evaluate FP, nutrition, WASH and early stimulation interventions. Activities will essentially focus on enhancing capacities in project management as well as M&E. (c) Experience sharing: South-south collaboration and exchanges to share experiences and learn from other countries or other provinces and communes will be supported by the Project. (d) Capacity strengthening of implementing actors: The Project will support activities aiming to develop, review or adapt learning material and to strengthen capacities of government actors (e.g. nurses, CHW, ML, etc.) and non-governmental actors (e.g. private sector, faith-based organizations, students from the schools of medicine and paramedical institutions, etc.) to ensure integration of nutrition and FP services as well as an adequate level of knowledge on community nutrition, C-IMCI, FP, WASH etc. by all actors. (e) Operational costs: The Project will support operational costs for central level directorates involved in the Project implementation. This includes office supplies and equipment as well as costs associated with workshops and meetings. 44. Communication: Communication is a central element of the Project for advocacy and social and behavior change required to address socio-cultural barriers to adoption of improved nutrition and reproductive health behaviors and practices. This should result in enhanced communication capacities of all stakeholders and facilitate behavior change thanks to harmonized messages on FP and nutrition. Expenditures will include technical assistance, equipment, supplies and operational costs. The Project will support the following interventions: (a) Communication strategy: The Project will support the elaboration of a revamped communication strategy integrating nutrition and fertility. Building on existing materials, the strategy will provide harmonized tools and strategies to address those issues, adapted to needs of the various actors and to various target groups. The communication strategy will cover a range of tools, from advocacy tools for Government officials and religious leaders, to general population communication and SBC tools. The Project will also support implementation of the strategy using traditional as well as innovative channels to maximize the impact of the strategy. (b) Branding: The communication strategy will entail a strategy for branding of inputs and services related to nutrition and FP to determine behavioral choice by building consumer relationships and identification with health behaviors and their benefits. The Project will support the implementation of the branding strategy to incentivize consumers to initiate or continue use of product and services supported by the Project. (c) Dialogue with religious and community leaders: The Project will support dialogue with religious leaders on sexual and reproductive health, in the context of the implementation of the two Gitega Declarations. The Project will also support specific advocacy and communication activities targeting religious and other community leaders to address some of the cultural/social barriers identified, strengthen dialogue on FP and ensure consistency of messages delivered to communities. (d) Sensitization on civil registration and vital statistics: The Project will support the Government’s efforts, in targeted provinces, to conduct training and inform on the importance of civil registration and vital statistics. The Project will support efforts to catch up on delayed registration of births and deaths in targeted provinces. 45. Building evidence: The Project will facilitate knowledge generation on nutrition and reproductive health, both from a technical and operational point of view. Learning and knowledge sharing will be facilitated at community level, as well as at local government and provincial levels to strengthen capacities Page 22 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) and awareness of issues. Expenditures will include technical assistance, surveys, workshops as well as printing and other operational costs. (a) Strengthening the evidence base on nutrition and reproductive health: The Project will support analytical work and technical assistance to guide policy decision and implementation of activities to enhance effectiveness towards the achievement of the Project’s development objective. Research and analysis needs will be identified throughout the implementation of the Project Needs already identified include research on the determinants of stunting in Burundi; a study on the effectiveness of natural contraceptive methods in the country; and the analysis of the food composition table. (b) Implementation research: The Project will support operations research using lessons learned from implementation. Operations research and process evaluations will allow changes in Project design and implementation modalities through corrective actions for increased impact. The Project will also support evaluation activities such as formative research, iterative prototyping and testing on specific areas of the program (e.g. delivery of integrated packages, communication messaging, delivery of early stimulation activities). Sub-component 2.2: Monitoring, evaluation and project management (US$2.4 million) 46. The Project will support supervision, coordination and oversight of the Project’s activities. It will support day-to-day management of Project activities by the Project Technical unit and Provincial Project Coordinators (PPCs) including fiduciary aspects. Component 3: Contingency Emergency Response Component (CERC) (US$0 million) 47. A CERC will be included under the Project in accordance with the World Bank Investment Project Financing (IPF) Policy, paragraphs 12 and 13 for Projects in situations of urgent need of assistance or capacity constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. 48. Project Cost and Financing: The proposed total project cost of US$30 million equivalent is supported through IPF over five years. The estimated project costs are provided in Table 3. Page 23 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Table 3: Project Costs by Component (in million US$) Project IDA Project Components cost Financing Component 1: Community interventions to increase coverage of nutrition 23.7 23.7 services and utilization of family planning services Sub-Component 1.1: Nutrition specific and nutrition sensitive interventions 12.8 12.8 Sub-Component 1.2. Family planning and reproductive health services 9.0 9.0 Sub-Component 1.3: Social and behavior change communication activities 1.9 1.9 Component 2: Strengthening institutions, leadership and monitoring 6.3 6.3 Sub-component 2.1: Strengthening institutions and capacities 3.9 3.9 Sub-component 2.2: Monitoring, Evaluation and Project management 2.4 2.4 Component 3: Contingency Emergency Response Component 0.0 0.0 Total Project Costs 30.0 30.0 C. Project Beneficiaries 49. The main Project beneficiaries will consist of children under-two and women of reproductive age in six provinces (Bubanza, Cankuzo, Cibitoke, Kirundo, Makamba and Muyinga)32 to reach them in the critical 1,000‐day window of opportunity, as most cognitive and physical development occurs between conception and two years of age. Interventions related to FP will focus on both women of reproductive age and men. Other beneficiaries will include adolescent girls to reach women early and to improve their health and nutrition status prior to entering their reproductive health years. Poorest households will benefit from improvements in access to water, hygiene, sanitation and nutrition sensitive initiatives. The public at large will benefit from the national communication strategy and revamped behavioral change communications. Finally, institutions, including central Government entities, provincial authorities and local authorities (communes) will benefit from institutional and capacity strengthening interventions. Table 4 summarizes the total number of beneficiaries of the Project by target group.33 Table 4: Project Beneficiaries (estimated numbers) Target group Total number of beneficiaries at the end of the Project Children under two 76,000 (30 percent in targeted communes) Children under five34 305,000 (50 percent in targeted communes) Vulnerable households 38,000 (7 percent in targeted communes) Women of reproductive age 450,000 (50 percent in targeted communes) 32 Five criteria were used to rank provinces by order of priority, using the recent DHS 2016/17 data: (i) Percentage of stunted children; (ii) Total number of stunted children; (iii) Percentage of women whose Body Mass Index (BMI) is less than 18.5; (iv) TFR; and (v) Percentage of women currently using modern contraceptive method. 33 Costing estimates suggest that the Project will allow to reach 36 communes, 620 hills (coverage of 70 percent), 1933 sub-hills (coverage of 50 percent) for nutrition specific interventions. Nutrition sensitive interventions would benefit 7 percent of households (vulnerable ones). 34 For interventions related to prevention and referral of acute malnutrition cases. Page 24 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) D. Results Chain 50. The Project aims to tackle the high stunting prevalence doubled with high fertility in targeted areas. This dual problem affects children’s chances to reach their full potential and to contribute to economic growth and prosperity in Burundi. 51. The overarching expected impact is to reduce demographic pressure and for children to reach their full potential through optimized healthy growth and improved childhood environment. The Project aims to reduce demographic pressure through increased coverage of FP services at community level, revamped and strengthened behavior change and communication strategy and dialogue with religious authorities to address cultural/social barriers to FP. The Project also aims to support a shift in approaches by turning the focus of the GoB from managing acute malnutrition to preventing stunting at the community level. The Project will optimize child growth through: improved community nutrition service delivery approach; social and behavior change at the community level; improved household feeding practices and child environment, including better access to quality nutritious foods as well as to water, hygiene and sanitation. 52. The Project’s theory of change relies on a set of critical assumptions that form necessary conditions for its success (Figure 4). The Project requires a convergence of efforts from multiple sectors at the community level; a participatory approach with sound ownership and strong community dynamic created around nutrition interventions will be essential. It is also expected that BCC activities will lead to effective behavior change on nutrition and FP to allow uptake and adoption of new services and practices at household level. Support from all actors, including the Catholic Church, will also be a determining factor of success for FP related activities. Page 25 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Figure 4: Project's Theory of change Page 26 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) E. Rationale for World Bank Involvement and Role of Partners 53. The rationale for the World Bank’s involvement lies in the fragile context of the country, the failure of existing mechanisms, the World Bank’s commitment to invest in Human Capital and funding shortage. With its global knowledge and ability to mobilize expertise and lessons learned from other countries, the World Bank can help address failure of existing mechanisms and develop a new approach to address the country’s pressing challenges related to stunting and fertility. The World Bank can play an important convening role to support mobilization and channel additional resources to scale up integrated FP and nutrition services. The World Bank’s continued support remains important in the current context with increasing pressure on fiscal space. 54. The Human Capital Project of the World Bank makes it a key actor to support the GoB in investing in its people. The Human Capital Project argues for increased investments in human capital because poverty, inequality, and other disadvantages hinder many families from investing in their children’s health, nutrition and education. The World Bank is committed to support Burundi, as one of the early adopters countries, to help it strengthen its human capital strategy and investments for rapid improvements in outcomes. The Nkuriza Project will contribute to support the GoB in transforming its human capital. 55. Given the multisectoral nature of the Project, the World Bank has a comparative advantage as it can mobilize technical expertise across sectors and ensure all projects supported by the World Bank in Burundi develop strategies to address stunting and food security, within their scope of intervention, and recognize the demographic challenges of the country. Since 2010, the World Bank has been one of the leading agencies engaged in supporting health system strengthening reforms including a revisited community approach for the delivery of health and nutrition services. The World Bank health and nutrition task team is working closely with task teams supporting the implementation of projects in the field of agriculture, WASH, social protection, education and jobs to develop synergies. A review of the three agriculture projects supported by the World Bank is underway; this review will lead to an action plan which will show how these projects will support nutrition sensitive interventions. Actors involved in the implementation of the Nkuriza Project and of agriculture projects will work closely together to ensure synergies. While the agriculture projects will support increased supply of adequate nutritious food and enhanced food security, the Nkuriza Project will stimulate demand for those quality food products. Support from agriculture projects will also be sought to increase coverage of nutrition sensitive interventions targeting vulnerable households benefiting from Nkuriza, as current resources enable a limited coverage for those interventions. 56. Since the political crisis in 2015, the number of development partners supporting Burundi including in the health sector has decreased drastically, leaving only a handful of donors. In the field of nutrition and food security, the main actors are currently the European Union (nutrition and food security), the World Food Program (WFP) (blanket feeding for children, school feeding), the Food and Agriculture Organization (FAO) (Income Generating Activities, kitchen garden, farmer field schools), UNICEF (training, FARN, ML) and the WHO (regulation and trainings). The four UN agencies are implementing the second phase of a joint nutrition project in Ngozi province to pilot nutrition specific and nutrition sensitive interventions. Large international NGOs, such as World Vision, Concern Worldwide and Catholic Relief Services are implementing projects for several donors. Reproductive health and FP interventions are mostly supported by UNFPA (procurement of inputs, Youth friendly health services, advocacy, supply chain management, training of trainers), the Embassy of Netherlands and Belgian Cooperation. Page 27 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 57. The Project will collaborate with development partners and non-state actors to develop synergies and benefit from their comparative advantage. The Project will rely on IAs for implementation of community level interventions using non-state actors with proven expertise in project management and daily representation in the field. The participation of those IAs, which have a good knowledge and understanding of local dynamics and interventions already in place, will facilitate day-to-day implementation and monitoring of Project activities. 58. The Project will rely on UN agencies for implementation of activities for which they have a comparative advantage. The Project will directly contract UNFPA for (i) procurement of contraceptives, lifesaving drugs and cycle beads; and (ii) technical assistance to improve the supply chain for contraceptives to provide last-mile reproductive health services in the Project’s targeted areas. The Project will also directly contract UNICEF for: (i) procurement of iron/Folic acid for pregnant women, micronutrients and other health commodities and supplies required for community level interventions; and (ii) technical assistance (e.g. training of trainers). If needs arise, the Project may also contract the WFP for blanket feeding or fortified flour. Finally, all UN agencies will play an important role for capacity building and communication activities around nutrition and fertility issues. F. Lessons Learned and Reflected in the Project Design 59. The Project draws on best practices and innovative approaches from Burundi and lessons learned from countries that successfully implement programs to tackle high fertility and stunting. Key lessons that have informed the design include: 60. Focus interventions on the first 1,000 days (from conception to two years of age) as they have a profound impact on ECD35 and longer-term effects on learning, health, nutrition, and ultimately income. Nearly 90 percent of a child’s brain development occurs from conception to the age of five and 80 percent before age three.36 Millions of young children are not reaching their full potential because of a complex interplay of inadequate nutrition and health, lack of early stimulation and learning, and exposure to stress that adversely affect their development. To ensure that children gain physical, social and emotional capacities to learn, earn, innovate and compete, it is therefore critical to seize that 1000 days window of opportunity to support the child’s brain and physical development. Consequences of children failing to reach their developmental potential are life-long and have multitude of effects including cognitive function, health, human capital, income, and equity. Furthermore, the earlier a child becomes affected, the greater the long- term consequences.37 61. Support a package of globally recognized high impact nutrition interventions. The Project will support implementation of nutrition interventions highlighted in the Lancet Series on Maternal and Child Nutrition in 2013 to address stunting and deficiencies of essential nutrients. The Lancet encourages more focus on nutrition-specific interventions and programs which address the immediate determinants of fetal and child nutrition and development – adequate food and nutrient intake, feeding, caregiving and parenting 35 According to Denboba et al. (2015), ECD refers to the cognitive, linguistic, socio-emotional and physical development of the child from prenatal stage up to aged eight. 36 Grantham-McGregor et al. 2007. Developmental Potential in the First 5 Years for Children in Developing Countries. Lancet 369 (9555): 60–70. 37 Allen and Gillespie. 2001. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions. Geneva in collaboration with the Asian Development Bank, Manila: ACC/SCN. Page 28 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) practices, and low burden of infectious diseases.38 62. Integrate nutrition and child stimulation to boost positive child outcomes, especially in the first 1,000 days. Early experiences indicate that incorporating early stimulation interventions into community- based health and nutrition services is more cost effective than delivering ECD interventions alone (Gowani et al., 2014). The Project will support an integrated community-based platform which provides a natural entry point to access vulnerable families, such as for engaging mothers (and other family members) in appropriate care and positive stimulation for children during their first years of life. The design of proposed interventions will be informed by the results of an ongoing household survey on early stimulation and child nutrition practices funded by the World Bank. 63. Focus on multisectoral community-based interventions to deliver nutrition specific and nutrition sensitive, including FP services. Both the Implementation Completion Report (ICR) of the Health Sector Development Support Project (HSDSP – P101160) and the impact evaluation of the nutrition PBF pilot (2014- 2017) report that in Burundi, human resources (at health facilities and at community levels) do not have the necessary skills to deliver quality nutrition services; availability of inputs, equipment, and protocols as well as the quality of supervision are also major weaknesses. The Project, with support of IAs, will go beyond what the health sector can deliver and arrange CHWs and other community actors around an integrated community platform to deliver an integrated and multisectoral package of nutrition and FP services. 64. CHWs alone cannot provide all services needed to address the determinants of malnutrition and high fertility. Health Promotion Technicians, Mamans Lumières39, Rural agronomists, social protection community workers, teachers, community leaders etc. will play a central role in the community platforms supported by the Project. A technical review of the role and capacity of these actors is underway (P165270). Given the multitude of actors, IAs will be critical to coordinate activities and ensure collaboration of those actors as well as day to day follow up of activities. 65. The Nkuriza Project has taken on board the recommendations of the World Bank’s Demographic Challenges and Opportunities in Burundi Advisory Services and Analytics (ASA) (2018).40 These include: (i) Scaling up FP/reproductive health services by piloting innovative approaches for reaching vulnerable women: this includes community-based distribution of contraceptives and leveraging ICT for FP outreach; and (ii) Support SBC communications at the community and national level and pilot alternative approaches to expanding access to youth-friendly FP and reproductive health services. The Project supports education, training, dialogue with religious institutions and targeted BCC activities for adolescent girls and boys related to FP. The Project will explore new approaches to ensure effectiveness of interventions targeting the youth, including peer learning. 38Victoria et al. 2010; Black et al. 2013. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 382(9890) 39 http://www.nursinglibrary.org/vhl/bitstream/10755/616176/1/2_Chaponniere_P_p79359_1.pdf 40 World Bank (2018). Demographic Challenges and Opportunities in Burundi. Washington, D.C.: World Bank Publications. Page 29 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 66. The institutional, implementation and coordination arrangements for the Project will be anchored on existing platforms adapted to reflect the need for a multisectoral approach. Annex 5 provides more details about roles and responsibilities of each entity for project implementation. 67. Coordination arrangements: Coordination arrangements provide the Government with the necessary leadership and stewardship functions to ensure ownership of the Project and alignment with the Government’s objectives and strategies. (a) Multisectoral Steering Committee (MSC): A SC, based on the SUN platform with participation of Ministers from ministries involved in the SUN platform will be constituted to provide guidance to the Project Technical Unit (PTU), monitor progress towards Project objectives and facilitate dialogue with participating stakeholders at all levels. The SUN Focal Point will chair the MSC. The MSC will validate the Project’s action plan, the Project’s key reference documents (project implementation manual (PIM), Annual Work Plan and Budget (AWPB), etc.) as well as monitor and supervise Project implementation. (b) Multisectoral Technical Committee (MTC): A MTC will be created and will meet monthly to discuss progress, identify challenges, and develop mitigation measures. It will constitute an inter-ministerial body comprising representatives with technical profile (Director level) from participating line ministries and key development partners involved in nutrition and demographic issues. This MTC will handle issues related to nutrition and FP for the Project as well as other Projects supported by other development partners to facilitate coordination, harmonization of approaches and institutionalization of the MTC. 68. National level implementation arrangements (Figure 5): (a) Project coordination: The MoH, through the General Directorate of Health Services and HIV/AIDS, will ensure oversight and coordination of the Project. The General Director of Health Services and HIV/AIDS will be the Project’s national coordinator, as is the case for other World Bank projects managed by MoH. (b) Formal agreement/Memorandum of Understanding (MoU) between MoH and other line ministries: As the Project is multisectoral by nature, the MoH will sign a formal agreement with other participating line ministries, namely the Ministry in charge of agriculture and livestock for activities related to nutrition sensitive interventions; the Ministry in charge of local development and home affairs for activities involving communes or related to civil registration; the Ministry in charge of education for activities involving schools and teachers; and the Ministry in charge of gender for activities related to women empowerment. Signing participating line ministries will be responsible for planning and budgeting annually the Project interventions within their scope of expertise and responsibility. Participating line ministries will work closely with MoH to support it in all capacities to ensure effective project implementation. (c) Project Technical Unit (PTU): The existing PTU within MoH will be responsible for day to day Project management. The team will be strengthened and high-level technical experts in nutrition, FP, agriculture, WASH, SBC, M&E, accounting and financial management (FM) will be recruited. A Technical Director will be recruited to manage this team of technical experts to ensure coherence of Project activities to achieve the PDO. The Technical Director will be the link Page 30 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) between the Project’s Coordinator and PTU. In addition to technical oversight, the PTU will handle fiduciary functions: (i) FM, including flow of funds to different stakeholders; (ii) procurement of goods to ensure efficiencies; (iii) securing consultant services; and (iv) oversight of safeguard provisions. 69. Province level implementation arrangements: (a) Provincial Project Coordinator (PPC): The PTU will recruit a PPC in each province. The PPC will compile and coordinate execution of action plans by the IA within the province. The PPC will report to the PTU and work in close collaboration with the Provincial deconcentrated technical services. (b) Implementing Agencies (IAs): The Project will recruit IAs to develop and implement interventions at provincial level and below and in close collaboration with Provincial deconcentrated technical services to coordinate all Project activities, including SBC, at commune and community levels. IAs will propose and develop consolidated plans for the commune by subdivisions (colline). The IAs will also be responsible for proposing implementation arrangements at the commune level. IAs will report to the PPC. 70. Community level implementation arrangements: The Project will follow the administrative structure from the commune to the communities to facilitate its implementation. Following the commune, the entry points will be the colline and the sous-colline. Within the six targeted provinces, the Project will cover 620 collines and 1933 sous-collines. (a) Community Steering Committees (CSC): CSC will be set up on each hill (commune subdivision) building on community dynamics with representation of different segments of the community. The CSC will support and oversee service delivery under the Project by supporting the planning process for the different activities at the community level; organizing periodic restitutions to the stakeholders to support continuous performance in the service delivery; and ensuring community mobilization and participation in the different activities. (b) Community actors: Community actors, such as CHWs, MLs, rural agronomists and community social workers will carry out activities at the community level. The Project will align to the GoB’s policy for community workers’ incentives. The KIRA Project already supports Community PBF in three provinces of the Project and ways to incentivize ML is under review. However, in areas where a Government incentives system is not already in place, IAs will propose an incentive mechanism for all community workers involved in implementation. (c) Provincial level Implementing Agencies: IAs (see above) will ensure oversight and supervision of community actors. As the Project promotes a participatory approach, IAs will propose innovative methods to ensure community involvement and ownership, thus ensuring sound strategies for sustainable community engagement. (d) Communities: They will identify MLs; facilitate service delivery (affecting a suitable place for activities); and support the delivery system actors to resolve arising issues. Page 31 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Figure 5: Institutional Arrangements B. Results Monitoring and Evaluation Arrangements 71. Results monitoring41: The second Vice-Presidency (VP), PTU and sectoral ministries will oversee monitoring of activities at the central level. PPC and provincial representations of sectoral ministries will monitor progress of activities. The IA will develop its own system for results monitoring and supervision of activities within its responsibility and the PTU will have the ultimate responsibility on results monitoring and results sharing with the World Bank. The PTU will consolidate technical and financial reports from IAs and PPC in Project areas. Progress reports will include information on Project activities, key indicators, 41Monitoring consists of tracking inputs, activities, outputs, outcomes, and other aspects of the project on an ongoing basis during the implementation period, as an integral part of the project management function. Page 32 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) beneficiaries, fiduciary and social safeguards. The PTU will review monitoring data to assess progress and propose remedial actions. 72. Indicators will be monitored through various data systems. This includes the Health Management Information System (HMIS), CHW monthly reports, the IAs’ quarterly reports, facility supervision reports and surveys. The PTU will be responsible for providing to the World Bank team necessary data and information to complete semi-annual Implementation Status and Results Report (ISR) and the ICR at the end of the Project. The intermediate result indicator on “Community steering committees meeting quarterly and providing inputs into the Project's quarterly reports, including on quality of and satisfaction with community nutrition interventions” will assess citizens’ engagement. An independent entity will develop appropriate instruments to be used during regular forums organized to collect citizens’ feedback on quality of and satisfaction with community nutrition interventions (both specific and sensitive). Specific and actionable recommendations will be formulated to ensure IAs address grievances, thus closing the feedback loop. 73. Evaluation42: The Project will incorporate multiple strategies to ensure ongoing learning and evaluation. Table 5 summarizes the different types of evaluations and surveys planned during the Project: (a) Midline and end‐line surveys: Population surveys will be conducted by an independent local entity in participating Project areas to assess baseline level and progress on FP and nutrition behaviors, practices as well as on coverage levels of key services. (b) Nimble evaluation on community delivery of contraceptives: A Strategic Impact Evaluation Fund (SIEF) grant was granted to the task team to conduct a nimble evaluation of community level delivery of self- injectables. The nimble evaluation will examine two interventions on their own and the combination of the two in the context of a cluster randomized control trial that will inform the Burundian Government during this transition period from traditional birth control measures to a more self-injection centered approach. (c) Quality of service delivery: One of the key factors for the effectiveness of the proposed interventions is the quality with which they are delivered. The PPC and provincial representations of sectoral ministries will perform supervision to review the quality of services delivered at community level by local implementation agencies, on a quarterly basis. In addition, other qualitative assessments and data quality audits may be performed, as deemed necessary. (d) Process documentation and evaluation: To support learning under the Project an operational research agenda will be developed. The learning agenda will focus on results and impact from: (i) convergence of nutrition specific and nutrition sensitive interventions; (ii) setup of community platforms around nutrition; (iii) service delivery modalities for community level FP interventions; (iv) collaboration and dialogue with Catholic church on FP; and (v) community-driven nutrition sensitive interventions. Lessons learned from these evaluations will be shared among Project areas and will inform ongoing improvements in the design and delivery modalities of the Project. 42 Evaluation refers to the process by which project results, impacts, and implementation performance are assessed. Projects are evaluated at discrete points in time (usually at the project’s mid-point and completion) along some key dimensions (i.e., relevance, efficiency, efficacy, impact, performance). Evaluations often seek an outside perspective from relevant experts. Page 33 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Table 5: Evaluations Timeline Topic Type of Y1 Y2 Y3 Y4 evaluation Coverage and utilization of Population X X nutrition and FP services Survey Nimble evaluation on self- Impact X X injectable contraceptives Evaluation Formative research, process Qualitative X X X X evaluation on specific areas of studies the Project 74. M&E institutional arrangements: The PIM will include details on the M&E arrangements, including roles and responsibilities, data sources and reporting frequency. A M&E Plan, elaborated by the PTU, will complement information provided in the PIM. M&E experts will be required at PTU level and within IAs. As a rule of thumb, information already produced by existing M&E systems will be used to report on progress and performance of the Project. When information is not collected, specific data collection mechanisms will be supported by the Project. The PIM will consider existing monitoring cycles in Burundi to evaluate when relevant data will become available. Actual values for indicators are updated and entered in the ISR result section following every implementation support official review. 75. M&E capacity strengthening: Capacity strengthening of institutions involved in Project implementation will be supported as need arises to carry out the M&E function. C. Sustainability 76. The prospects for sustainability of activities supported under the Project are considered reasonably good, both from an institutional and financial perspective. First, the high‐level political commitment with a SUN Secretariat established at the level of the Second Vice Presidency will strengthen ownership of the nutrition and FP agenda at all institutional levels. Second, the Project gives a major importance to capacity building and advocacy activities to raise awareness on stunting and fertility issues in the context of Burundi, as well as to enhance technical capacities at all levels within the different line ministries, local governments and local actors to deliver coordinated nutrition and FP interventions. Third, the design leverages and builds on existing institutional structures such as the CHW platform which is being put in place, the national PBF scheme, and an experienced implementation unit at the level of the Ministry in charge of Health. Fourth, the Project puts emphasis on BCC which can have a long-term effect on household behaviors and practices. Finally, the Project is designed to pilot a new multi-sectoral approach in a limited number of provinces which have been prioritized based on needs. The Project will adopt a learning by doing approach with lessons learned informing potential scale up of the proposed approach to other provinces. 77. From a financial perspective, the Project represents a significant increase in funds allocated to the health and nutrition sectors. In 2018, data showed that the total envelope for health was about US$48 million; the Project’s investment will represent a significant increase in resources available to the sector (+US$30 million over five years). Burundi’s health sector has historically been funded mainly by external resources, with external partners covering 92 to 98 percent of the resources for health. Burundi will benefit Page 34 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) from stable, predictable resources for health and this will allow the country to make systematic investments in their population’s health and productivity potential. IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 78. Controlling population growth and improving child health and nutrition is critical for achieving the World Bank goals of reducing poverty and boosting shared prosperity. More than half of the children under five living in Burundi are stunted, undermining the human and economic potential of the country. Food insecurity, poverty, limited access and/or quality of health care services, inadequate knowledge of infant and child feeding practices, and high fertility rate are key drivers of Burundi’s suboptimal childhood development. At current fertility rates, 25 million additional children are expected to be stunted by 2050. Chronic malnutrition takes its toll over a person’s entire life by irreversibly stunting a child’s physical and intellectual growth, which, in turn, undermines opportunities to join the labor market, be productive, and earn a decent income that prevents them from falling into poverty. The economic costs of malnutrition in Burundi were estimated at US$102 million each year in 201343. 79. The specific objective of the Project is to increase utilization of FP and improve the nutritional status of children and thus reduce demographic pressure and stunting. This will be achieved through the PDO of increasing coverage of community-based nutrition interventions among women of reproductive age and children under-two and utilization of FP services in the Project areas. By doing so, the Project will address the four key risks faced by children in their first 1000 days: inadequate food intake, infections, pregnancy and birth complications, and inadequate stimulation. 80. Controlling population growth and spacing births is a recognized strategy to decrease maternal and child mortality, reduce health systems’ costs, and increase women’s opportunities to pursue higher education, stay in the labor market, and earn higher wages (JEC).44 FP directly reduces the number of maternal deaths45 because of the lower likelihood of pregnancy associated complications such as abortions, pregnancy in early age, and closely spaced births. By avoiding birth complications, FP also averts costs to the health system and frees up resources that can be used to improve care in other areas. Benefits to mothers translate in good part into benefits for children, as lengthening birth intervals increases child survival rates and resources available to families to care for children, including higher chances for education. In addition to these direct benefits for mothers and children, FP can reduce poverty by empowering women to study longer and make a higher wage over their working life. For example, according to a study conducted in the US, women accessing pills had an 8 percent increase in hourly wage by age fifty (Bailey, 2012).46 81. There is strong and growing evidence that improving young child nutrition is one of the best investments a country can make for its human and economic development. At the individual level, a person’s potential lifetime earnings are 10 percent higher than that of a person who suffered from chronic 43 https://www.unicef.org/nutrition/burundi_69651.html 44 Joint Economic Committee. (2015). The economic benefits of Access to family planning. United States Congress, Washington DC. 45 Ahmed S, Li Q, Liu L, Tsui A. (2012). Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet, 380: 111-125. 46 Bailey M, Herbshbein B, Miller AR. (2012). The Opt-In Revolution? Contraception and the Gender Gap in Wages. NBER Working Paper 17922. Page 35 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) malnutrition during childhood. According to recent estimates, US$1 invested in stunting reduction generates about US$18 in economic returns47 and could increase GDP by 4 to 11 percent.48 82. The pathways through which reduced malnutrition fosters economic development are multiple. Firstly, malnourished children are at higher risk of dying from different diseases (WHO, 2000), thus depriving the country of significant human capital that can contribute to the economic development of a country. Secondly, malnutrition affects health outcomes in life, which in turn leads to suboptimal work productivity. A literature review of medical evidence from Asian, African, and South American developing countries, Walker et al. (2007)49 and Victoria et al. (2008)50 shows that undernourished fetuses and children in the first 24 months of life are associated with a list of increased health risks (e.g. higher blood pressure), less schooling, deficits in cognitive skills, and reduced economic productivity and labor income. Consequently, children who experienced chronic malnutrition are more likely to be of a disadvantageous socioeconomic status (Case and Paxson, 2006)51 and thus at higher risk of being poor. Moreover, women who experienced chronic malnutrition are at higher risk of giving birth to low birth weight children, which in turn affects the long-term development of the newborn. As such, malnutrition brings an intergenerational impact of suboptimal health and cognitive outcomes, impoverishment, and missed opportunities for economic development. 83. The socio-economic cost of unmanaged population growth and chronic malnutrition in Burundi is enormous. Without an immediate, large-scale, and sustained effort targeting mothers and children over the next years, Burundi will be increasingly burdened by a cohort of unhealthy, unskilled and economically unproductive persons. 84. The cost benefits analysis (CBA) built directly on the PDO, while recognizing the greater complexity of the underlying causal chain of the interventions on the outcomes and economic benefits. The Project’s effectiveness/benefits were estimated separately for each component and by province covered by the Project and then transformed into monetary value in aggregated form following the framework displayed in Figure 6. 47 Hoddinott, Alderman, Behrman, Haddad, & Horton (2013). The economic rationale for investing in nutrition. Maternal and Child Nutrition 9(Suppl. 2): 69- 82. 48 Horton S. and R. Steckel. 2013. “Global Economic Losses Attributable to Malnutrition 1900–2000 and Projections to 2050.” In The Economics of Human Challenges, ed B. Lomborg. Cambridge, U.K.: Cambridge University Press. 49 Walker, S.P., Wachs, T.D., Gardner, J.M., Lozoff, B., Wasserman, G.A., Pollitt, E., Carter, J.A. and International Child Development Steering Group, 2007. Child development: risk factors for adverse outcomes in developing countries. The lancet, 369(9556), pp.145-157. 50 Victoria C, Adair L, Fall C, et al. (2008). Maternal and child undernutrition: consequences for adult health and human capital. The Lancet, 371 (9609):340– 357. 51 Case, A., Paxson, C., 2006. Children’s health and social mobility. Opportunity in America 16 (2), 151–173. Page 36 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Figure 6: Project’s Impact and Economic Benefits Modelled in the CBA Demand ↑ Use of modern ↓MMR Number of active and stimulation for contraceptives productive individuals reproductive methods preserved health services ↓U2MR Multisectoral, ↑ Service utilization communitybase Children whose d nutrition potential productivity interventions ↓Stunting was preserved Step 1 Step 2 Step 3 85. All benefits and costs were assumed to result from the Project since the Government is currently not systematically funding community-based nutrition interventions. The total costs of US$30 million were assumed to be disbursed over the Project’s lifecycle as shown in Table 6, with lower disbursement on the first and last year due to Project’s implementation setup and closing phase. Table 6: Project Disbursement Over Time in US$ Million per Year 2019 2020 2021 2022 2023 2024 Total US$ million 0.66 3.18 5.03 6.50 8.17 6.46 30.0 86. The impact of the Project’s interventions was estimated separately for each component in terms of lives saved and human capital/potential productivity preserved (Figure 6, Step 2). For Sub-component 1.1 on community-based nutrition interventions, the number of child deaths averted and the number of cases of stunted children averted, among children below the age of 2 were estimated. This was done using a back of the envelope approach based on global evidence on the impact of a suite of interventions designed to improve child nutrition and prevent related diseases (Bhutta et al., 2008) 52. The most conservative study estimates are that a package of nutrition-related interventions reduces child deaths by 0.173 percent and child stunting by 0.241 (up to 24 months). For Sub-component 1.2 on reproductive health services, we estimated the number of maternal lives saved resulting from the estimated increase in use of modern contraceptive methods. Like for Sub-component 1.1, we used global evidence on the impact of contraceptive use on maternal deaths. The study by Ahmed et al. (2012) 53 found that the total impact of increasing use of contraceptive methods, i.e. through spacing births or reducing the number of pregnancies and thus deliveries and unsafe abortions, reduces maternal deaths by 44 percent. The Project’s impact in terms of number of maternal lives saved, child deaths averted, and number of cases of children stunted averted is summarized in Table 7. For both components we made the conservative assumption that most of the benefits will be gained 1 year after implementation starts, i.e. from 2020. 52 Bhutta ZA, Ahmed T, Black RE, et al. (2008). What works? Interventions for maternal and child undernutrition and survival. The Lancet. Maternal and Child Undernutrition Series. 371 (9610): 417-440. 53 Ahmed S, Li Q, Liu L, Tsui A. (2012). Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet, 380: 111-125. Page 37 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Table 7: Estimated impact of the Project, by year Aggregated Impact 2020 2021 2022 2023 TOTAL Maternal deaths averted 618 1,270 1,957 2,685 6,530 Child deaths averted (<2 year) 103 140 289 445 977 Children <2 stunted averted 1,853 2,366 4,864 7,502 16,585 Note: Impact of the interventions was estimated for each province and then aggregated. 87. The Project’s benefits were then converted into monetary terms (Figure 6, Step 3). Each life saved was valued one time the GDP per capita in Burundi, while each case of child stunting averted was valued 66 percent of the GDP per capita based on Hoddinott et al. (2013) 54 who estimated the economic consequences of stunting throughout the lifecycle. The authors found that a stunted child has 66 percent lower consumption expenditure in adulthood. Hoddinott et al. (2013) interpret the change in per capita consumption as change in per capita permanent income. To be more conservative, we assumed that only 30 percent of the GDP (Lübker)55 comes from wages, and thus averting stunting will preserve 20 percent of the GDP per capita (i.e. 0.66*0.3). Benefits were calculated over the lifetime of children, because the developmental and cognitive benefits resulting from proper nutrition persist for life. Children were assumed to join the labor market at the age of 18 and retire at the age of 65, while women were assumed to be 28- year-old at the time of receiving the interventions, i.e. the median age of mothers at first birth (25 years) plus half the average fertility rate (6.1). 88. Once benefits are translated into monetary terms, the following base-case assumptions were made to calculate the key metrics of cost benefits analysis: benefits and costs were discounted at 3 percent over time, the economy was assumed to grow at 1 percent based on current IMF estimates56, and we assumed that 80 percent of women are employed in Burundi (ILO estimates) 57 and thus contribute to economic growth. Under these base-case assumptions, the Project yields a ratio of benefits to costs (BCR) of 3.1, suggesting that for every dollar invested, the Project is expected to yield an economic return of about 3 dollars, i.e. three times higher (Table 8). The initial investment of about US$30 million is expected to generate economic benefits with a NPV of US$44.3 million. The estimated internal rate of return (IRR) is 11 percent, which is slightly higher than Burundi’s average interest rate in the last 10 years (2007-2017) at 10.7 percent58. 89. Sensitivity analyses showed that the results of the CBA were sensitive to changes in key modelling assumptions, but the main conclusions remain unchanged, i.e. that the investment was justified on economic grounds (Table 8). Higher discount rate (from 3 to 6 percent) or no economic growth would somewhat reduce the economic return of the Project investment, yet it would remain economically sound with a benefit to cost ratio of 1.8 and 2.4, respectively. If instead we assumed that changes in consumption due to reducing stunting translate 1:1 into changes in permanent income (Alternative impact of stunting on GDP), then the BCR would further increase from 3.1 to 3.6 and the NPV of the investment would raise to more than US$54 million. Similar economic return is expected if we assume 100 percent female labor 54 Hoddinott J, Alderman H, Behrman JR, Haddad L, Horton S. (2013). The economic rationale for investing in stunting reduction. Maternal and Child Nutrition, 9 (2): 69-82. 55 Lübker, M. 2007. Labour Shares. Geneva: Policy Brief, Policy Integration Department, International Labour Office. 56 https://www.afdb.org/en/countries/east-africa/burundi/burundi-economic-outlook/ 57 https://data.worldbank.org/indicator/SL.TLF.CACT.FE.ZS?locations=BI 58 Retrieved from the website Trading Economics in August 2018. Page 38 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) participation in the economy. Table 8: Results from Cost Benefit Analysis - base-case scenario and sensitivity analyses BCR IRR NPV 11% US$44.3 Base-case scenario 3.1 million Sensitivity analysis Discount rate (6%) 1.8 11% US$14.8 No GDP growth 2.4 9% US$29.8 Alternative impact of stunting on GDP 3.6 11% US$54.7 Women participation in economy (100%) 3.6 13% US$54.1 90. The CBA takes a conservative approach in estimating the benefits from the Project and presents some limitations. Firstly, the CBA included the benefits of nutrition interventions for children up to two years, while evidence showed that the benefits persist at least up to 36 months. Secondly, the nutrition interventions bring significant direct benefits also to mothers, but those benefits were not accounted for in the analysis. Thirdly, some data was available only at the national level (e.g. maternal mortality) and thus the CBA is likely to have underestimated the benefits of the interventions because the Project is targeting the most affected provinces in the country. B. Fiduciary (i) Financial Management 91. The country’s public financial management (PFM) system will not be fully used for this Project. The fiduciary management of the Project will be handled by the fiduciary team of the ongoing KIRA Project (P156012). With the added responsibilities, the KIRA fiduciary capacity will be strengthened with an internal auditor and one accountant. The budgeting, funds flows, accounting, internal control, and financial reporting were assessed as effective. There is no overdue Interim Financial Report (IFR). The first audit report for KIRA was received in December 2018 and the audit opinion was unqualified. There is currently no head of the finance unit. Three months after effectiveness date, the terms of references (ToRs) of the FM Specialist should be revised, to make this person become the Head of the Finance unit supervising the finance team (chief of accounting, accountants, logistician). The Head of the Finance unit will still be reporting to the Directeur General des resources. 92. The FM risk is considered Substantial. This rating is driven by the inherent fiduciary risk at country level but also the complexity of the Project with (i) many beneficiaries including communities and non- government entities; (ii) the geographic scope of project’s activities; and (iii) a large number of agreements with technical and implementing agencies during the Project implementation. IAs have not yet been recruited yet; once recruited, the World Bank may request a FM assessment regarding the volume of funds each IAs will manage. (ii) Procurement Page 39 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 93. Applicable procurement rules and procedures. Procurement will be carried out in accordance with the Procurement Regulations for IPF Borrowers, namely Procurement in IPF: Goods, Works, Non-Consulting and Consulting Services, dated July 1, 2016 as revised in November 2017 and August 2018; “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants (revised as of July 1, 2016,)”; and provisions stipulated in the Financing Agreement. For national competition, the Borrower and the World Bank will agree on provisions to consider for the bidding document to be used for consistency between national procurement procedures and the new procurement framework. Those provisions will include, among others, provisions for confirming the application of, and compliance with, the World Bank’s Anti-Corruption Guidelines, including without limitation the World Bank’s right to sanction and the World Bank’s inspection and audit rights. 94. Procurement capacity assessment. The Project will be under the responsibility of the KIRA Project fiduciary team. This procurement team is one of the most qualified and experienced in Burundi. It brings together two Sr Procurement Specialists and one Junior Procurement Specialist who together accumulate more than twenty-nine years of experience in the implementation of projects financed by the World Bank. The experience and the success of this team make it very popular, this team is in great demand to support IDA financed operations. Thus, this team is already in charge of the procurement activities for the KIRA Project (P156012), Regional Great Lakes Emergency Sexual and Gender Based Violence and Women's Health (P147489) and Regional East Africa Public Health Laboratory Networking (P111556) projects. With the added responsibilities, it is important to reinforce the team with additional staff and means. Hence, the main recommendation of the capacity assessment is to strengthen the KIRA Project fiduciary team with at least another junior procurement specialist. It was also noted the need to put in place a robust coordination mechanism understood and accepted by the management of all structures and project implementation units currently assisted by the KIRA fiduciary team. This aspect will be elaborated in the PIM. 95. Preparation of Project Procurement Strategy for Development (PPSD). In accordance with the requirement of the World Bank procurement regulations, the Project KIRA fiduciary team together with the core Project preparation team from the Borrower prepared and developed a short form Project Procurement Strategy for Development (PPSD). The PPSD reviews the experience and capacity of all the parties involved in procurement activities required by the Project. The PPSD includes the Project procurement plan for the first 18 months. The PPSD provides the basis and justifications for procurement approaches and decisions including market analysis and selection methods. Following the market analysis, the PPSD recommends that 75 percent of the amounts for the procurement of goods go to the United Nations (UNICEF and UNFPA) for nutrition, medicines and medical devices, due to their renowned expertise and ability to purchase efficiently high volumes of commodities. Page 40 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) C. Environmental and social Safeguards (i) Environmental Safeguards 96. The expected benefits of the Project, which include backyard/community gardens, small livestock husbandry, use of improved seed varieties and animal stocks, food conservation and transformation technologies, accompanied by enhanced social and BCC will greatly outweigh the negative impacts likely to be generated. The Environmental safeguard policy that is triggered is OP/BP 4.01 (Environmental Assessment) because the likely negative impacts resulting from the Project activities will be limited to possible generation of wastewater and medical wastes, worker health and safety, and community health and safety. The Project is assessed as an environmental category “B” with limited, temporal and reversible impacts. These impacts were identified in the Environmental and Social Management Framework (ESMF) document which provides guidance on how to manage and set up mitigation measures for those impacts. The ESMF was disclosed in Burundi and by the World Bank on March 5, 2019. It provides essential baseline data, confirms policies that are triggered, assesses likely impacts, and proposes measures for the strengthening of institutional capacity. It also provides the basic criteria and procedures for screening all interventions. As the KIRA Project has prepared an updated Medical Waste Management Plan (MWMP), this Project will use the same document to mitigate medical wastes during implementation. 97. Climate Co-benefits: A Climate Co-Benefits assessment was performed. The Project is not expected to contribute to the increase of carbon sequestration. However, it will contribute to adaptation co-benefits through small agriculture interventions (kitchen gardens). Targeted households will carry out some community initiatives for agriculture production. These will increase intake of diversified quality food among local communities. Those interventions/measures will increase adaptation to climate change risks such as food insecurity. (ii) Social Safeguards 98. The social impacts expected of the Project are overwhelmingly positive. The persistence of high fertility and stunting, which the Project seeks to address, are some of the most important obstacles in Burundi’s human development and contribute to the country’s continued fragility. OP 4.12 on Involuntary Resettlement is not triggered, as the Project does not include any works that could affect beneficiaries’ land, structures, or economic livelihoods. OP 4.10 is triggered given that the Project will include the indigenous Batwa community of Burundi, a historically marginalized group. An Indigenous Peoples Planning Framework (IPPF) was disclosed in Burundi and by the World Bank on March 5, 2019. On the basis of the IPPF, and prior and informed consultations, an Indigenous People’s Plan (IPP) will be prepared to assess the impact of the Project on the Batwa population, set out measures to avoid any negative impacts, and establish a specific strategy to deliver Project benefits to the Batwa population. (iii) Grievance Redress Mechanisms 99. The Project will develop a functional Grievance Redress Mechanism (GRM) to collect citizens’ feedback and address grievances. This will be carried out through regular forums/consultations at the colline level. Project field offices will also receive, and record grievances and inquiries received. Those grievances Page 41 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) that cannot be resolved at the local level will be channeled to the PTU for follow up. Grievances received will be analyzed and reported regularly to improve the services delivered by the Project. 100. 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 101. The overall risk of the Project is considered substantial. The key risks and proposed mitigation measures are described below. 102. Political and governance risks are high. There is a risk of a protracted repeated crisis and a fragility trap if the underlying factors of the 2015 political crisis are not addressed. Governance remains ineffective in Burundi, constrained by decades of war, political instability, and weak institutions. Burundi ranks among the lowest countries on international governance indicators. A deteriorating political situation could prevent implementers from focusing on the Project’s technical and financial management. In that context, it is envisioned to build on pre-existing arrangements that have proven to be effective and to anchor the Project overall management within the MoH as this arrangement has shown to work well even in times of crisis. While there are risks, these will be managed from the fiduciary perspective. 103. The security risk (other risk) is rated high. Insecurity related to the political and governance risks can have a negative impact on implementation of activities under the Project. Component 3 of the Project could be activated to deal with an emergency related to insecurity. 104. The macroeconomic risk is rated high. The economy is recovering from the 2015 crisis, but only slowly. The country is still facing acute economic difficulties in the post-2015 election period including the Government’s tight fiscal situation and external sector vulnerabilities. Burundi’s macroeconomic outlook remains fragile and imbalances will likely persist. Measures to mitigate these risks are limited within the Project, but the situation will be monitored closely, as increased food insecurity may negatively impact the ability of the most vulnerable to meet basic needs and foreign currency shortages affect the supply of medicines. 105. The risk related to sector strategies and policies is substantial. The FP Acceleration Plan (2015-2020) launched in 2014 seeks to speed the uptake of FP services to achieve a contraceptive prevalence rate of 50 percent at the national level by 2020, instead of achieving it by 2025 as stated in the Vision 2025 policy Page 42 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) document. The acceleration plan presents several strategies that reflect a solid understanding of good practices but addressing the barriers to demand for FP in Burundi is challenging and ways and resources through which behavior change is expected to happen are not clearly defined. The multisectoral strategy for malnutrition that was planned to end in 2017 has been extended to cover 2018 and the second phase is currently under preparation. However, the implementation of the first strategy has been weak, not costed and coordination efforts by the SUN secretariat weakened by the absence of adequate financial and human resources. There is no effective platform to coordinate nutrition interventions in the country. Interventions supported by the Project and aiming to strengthen institutions and to build capacities of the main actors will contribute to mitigate this risk by improving planning, monitoring and reporting capacities at various levels. 106. The risk related to technical design is substantial. It is the first attempt to develop a multisectoral intervention to address chronic malnutrition in the country and to propose an integrated response to the malnutrition and fertility challenges of the country. Project implementation will rely on effective set-up of community platforms and move from vertical to horizontal approach, which requires a significant shift from current projects implemented in the country. The proposed approach will require a major mind shift from all actors, from the central to the community level to work horizontally, across sectors and in non-traditional settings as traditional structures (e.g. health centers) will not be at the center of interventions. The risk related to technical design will be mitigated by the recruitment of IAs which will be responsible for coordinating multisectoral interventions at the local level and for ensuring community level platforms are fully functional. 107. The risks in terms of institutional capacity for implementation and sustainability are substantial. The implementation will involve several agencies and activities at different levels, from the highest level in government (second VP) to the communities and will require signature of MoUs between line ministries to facilitate the multisectoral approach. To date, there is no institution with a multisectoral dimension with the capacity to implement the Project. As far as implementation is concerned, recent events reflect a difficult environment for UN agencies and international NGOs to work effectively in the country. To mitigate this risk, the Project will build on the institutional capacity for implementation built by the HSDSP and KIRA Projects at the MoH as it is the only entity with some in-house capacity and experience implementing World Bank projects. Overall Project oversight at strategic level will be done by a strengthened SUN platform as it is the only entity with the mandate to convene multiple sectors and instigate multisectoral interventions. Currently the SUN platform has no technical or financial capacity to undertake Project coordination or effectively pursue activities within its mandate. Strengthening the SUN platform will however depend on political commitment as well as support received from other development partners. Overall, to mitigate the sustainability risk, the objective is to mainstream interventions at all levels rather than promote a Project approach. 108. Fiduciary risks are substantial. Because of the macroeconomic situation described above, there is a high risk of budget support misappropriation and elite capture. In addition, all international agencies and organizations have been invited to close their bank accounts in commercial banks and transfer their dollar- denominated funds to the Central Bank. Although it is an international practice, in the current special context, this decision could exacerbate the risk of misappropriation. It could also cause payment and Project implementation delays. Finally, the large number of transactions with a significant number of beneficiaries and MoU with non-government agencies coupled with the inherent country fiduciary risk may pose some challenges. Mitigation measures include: (i) implementation of the Project through the existing technical unit Page 43 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) at MoH overseeing other World Bank funded projects for the MoH, which has shown strong management abilities even in the current fragile context; (ii) consolidation of the fiduciary responsibility within the well experienced FM team overseeing other World Bank-funded projects; (iii) funds for community level interventions would flow directly to IAs which will be recruited on the basis of a strong FM system satisfying World Bank’s FM requirements; (iv) development of the Project’s Implementation Manual which includes fiduciary arrangements in accordance with the World Bank procedures; (v) continued Project support to the MoH of high-level local experts in the areas of FM/accounting and procurement; and (vi) at least two FM onsite supervisions visits will be conducted every year to ensure that strong FM systems are maintained for the grant throughout the life of the Project. 109. Environmental and social risks are moderate. Stimulation of demand for pre-natal services will lead to an increase in medical waste as well as water and sanitation facilities. Maternity services involve medical waste, biological waste, and fecal waste. As frequent diarrhea is one of the primary predictive factors for death of children under the age of two in Burundi, communicating better hygiene will include water and sanitation interventions. It is anticipated that there will be no need for involuntary taking of land or limiting of access to livelihoods associated with this Project. MoH implementing capacity specific to environmental impact assessment, mitigation, management, and monitoring is strong, with demonstrated ability to comply with World Bank and Burundi national safeguards policies in the previous health interventions. In addition, the safeguards policy on indigenous peoples (OP4.10) is applicable to the indigenous Batwa community of Burundi which is known to have a higher than national average mortality rate of children under 5 years old. This highly marginalized group is at risk of not receiving the benefits of the Project if special attention is not paid to reaching out to them. The implementing agency is progressively improving its capacity to reach out to this community; experience has been gained first from the HSDSP and now from the ongoing KIRA Project. This will serve the Project and it will be important to devise a specific strategy to deliver Project benefits to Batwa communities. The gender-based violence assessment performed for the project revealed a low risk; nevertheless, this dimension will be closely monitored during project implementation. 110. Stakeholders risks are substantial. Awareness about the issues the Project intends to address (i.e. stunting and fertility) is currently limited in Burundi. Therefore, support from policy makers and from other major stakeholders can be lacking or inadequate and can impact the Project’s outcomes. Fertility and modern contraception are sensitive issues that can raise opposition from key stakeholders in the society, in particular from religious leaders. To mitigate this risk, the Project aims to develop a strong communication and advocacy strategy, targeted to key stakeholders to ensure their adhesion to the Project’s objectives. The Project also aims to work with faith-based health facilities and religious actors for service delivery to foster . collaboration and understanding on the Project’s intended benefits. Page 44 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) VI. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Burundi Investing in Early Years and Fertility in Burundi (NKURIZA) Project Development Objectives(s) Increase the coverage of community based nutrition interventions among women of reproductive age and children under two and to increase utilization of family planning services in targeted areas Project Development Objective Indicators RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Increase the coverage of community based nutrition interventions among women and children People who have received essential health, nutrition, and population 0.00 100,000.00 250,000.00 600,000.00 1,000,000.00 (HNP) services (CRI, Number) Number of women and children who have received basic 0.00 100,000.00 250,000.00 600,000.00 1,000,000.00 nutrition services (CRI, Number) Children 0-23 months receiving essential community-based nutrition and early stimulation 0.00 5.00 10.00 20.00 30.00 services in targeted areas (Percentage) Children 0-23 months showing adequate weight gain in targeted 0.00 25.00 30.00 40.00 55.00 areas (Percentage) Page 45 of 66 The World Bank Investing in Early Years in Burundi (NKURIZA) (P165253) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Increase utilization of family planning services Women using modern contraceptive methods in targeted 19.90 22.40 24.90 27.40 29.90 areas (Percentage) Couple-Years Protection (CYP) in 531,695.00 638,034.00 765,641.00 918,769.00 1,102,522.00 targeted areas (Number) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Community interventions to increase coverage of nutrition services and utilization of FP Community steering committees meeting quarterly and providing inputs into the project's quarterly 0.00 49.00 107.00 124.00 133.00 reports, including on quality of and satisfaction with community nutrition interventions (Number) Mothers participating in behavior change activities (cumulative) 0.00 57,167.00 120,050.00 264,111.00 607,454.00 (Number) Targeted households with targeted groups (children under two, pregnant and lactating women, adolescent girls) benefiting from 0.00 8,281.00 27,604.00 33,125.00 35,886.00 nutrition sensitive community initiatives (Number) Pregnant women benefiting from 0.00 170,091.00 369,098.00 800,943.00 1,738,047.00 Page 46 of 66 The World Bank Investing in Early Years in Burundi (NKURIZA) (P165253) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 iron and folic acid supplementation (cumulative) (Number) Community Health workers trained to deliver Sayana Press 0.00 30.00 50.00 75.00 100.00 (Percentage) Strengthening institutions, leadership and monitoring Faith-based health facilities staff trained on family planning methods 0.00 40.00 50.00 60.00 80.00 and referrals in in targeted areas (Percentage) Number of people trained in Masters level training (1 year) (nutrition, reproductive health, and 0.00 3.00 6.00 9.00 environmental public health) (Number) IO Table SPACE UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection The indicator measures the number of women Reports from People who have received essential and children who have MOH and Annual implementin health, nutrition, and population (HNP) received basic nutrition Implementing agencies g agencies services services through operations supported by the World Bank. Page 47 of 66 The World Bank Investing in Early Years in Burundi (NKURIZA) (P165253) The baseline value for this indicator is zero. Subsequently, the data should be cumulative; the cumulative value is added year after year; that is, for Year 1 the value for Year 1 is reported, and for Year 2, Year 1 + Year 2 is reported. Implementin Number of women and children who Quarterly Implementation report Implementing agency g agency have received basic nutrition services Children benefiting from essential community-based Children 0-23 months receiving essential nutrition and early Implementin Quarterly Implementation report Implementing agency community-based nutrition and early stimulation g agency stimulation services in targeted areas services/targeted population of children in project areas *100 % children 0-23 showing Children 0-23 months showing adequate adequate weight gain in Monthly Project MIS Implementing agency weight gain in targeted areas project areas/weighed children*100 Women using modern Midline and Women using modern contraceptive contraceptive method/ 80% Endline Survey DSNIS methods in targeted areas women of reproductive age surveys in project areas * 100 Couple-Years Protection (CYP) in targeted Estimated protection Midline and Survey MOH areas provided by family planning endline Page 48 of 66 The World Bank Investing in Early Years in Burundi (NKURIZA) (P165253) services during a one year surveys period, based upon the volume of all contraceptives sold or distributed free of charge to clients during that period. CYP is calculated by multiplying the quantity of each method distributed to clients by a conversion factor, which yields an estimate of the duration of contraceptive protection provided per unit of that method ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Community steering committees meeting Number of local steering quarterly and providing inputs into the committees meetings Implementati Annual Implementing agency project's quarterly reports, including on organised in collines of on reports quality of and satisfaction with project areas community nutrition interventions Number of mothers Implementin Mothers participating in behavior change benefiting from behavior Quarterly Implementation reports Implementing agency g agency activities (cumulative) change activities; cumulative Targeted households with targeted Cumulative number of Quarterly Implementin Implementation reports Implementing agency groups (children under two, pregnant and Households/ targeted g agency Page 49 of 66 The World Bank Investing in Early Years in Burundi (NKURIZA) (P165253) lactating women, adolescent girls) households in project areas benefiting from nutrition sensitive community initiatives Number of Pregnant women Pregnant women benefiting from iron and Monthly DHIS2 MOH receiving supplementation folic acid supplementation (cumulative) in project areas Community Health workers trained to Trained CHW/targeted CHW Quarterly MOH MOH deliver Sayana Press in project areas *100 Faith-based health facilities staff trained Staff trained (at least 1 per Ministry of Quarterly Implementation reports PNSR (MOH) on family planning methods and referrals facility)/Targeted staff in health in in targeted areas project provinces*100 Number of students Number of people trained in Masters level registered to a masters level Annual MOH MOH training (1 year) (nutrition, reproductive training in nutrition, health, and environmental public health) reproductive health or environmental health ME IO Table SPACE Page 50 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ANNEX 1: Implementation Arrangements and Support Plan COUNTRY: Burundi Investing in Early Years in Burundi (NKURIZA) Financial Management 1. For the proposed project, it has been agreed that the existing KIRA Project FM unit within the Direction Générale des Ressources (General Directorate for Resources or DGR) will be responsible for day- to-day coordination of the Project’s FM activities. The objective of the FM assessment of the Implementing Unit was to determine: (i) whether there were adequate FM arrangements in place to ensure the funds will be used for the intended purposes in an efficient and economical manner and capable of correctly and completely recording all transactions related to the Project; (ii) the Project’s financial reports will be prepared in an accurate, reliable and timely manner; and (iii) the Project assets will be safeguarded. The FM assessment was carried out in accordance with the World Bank Directive: FM Manual for World Bank IPF Operations issued February 4, 2015 and effective from March 1, 2010; and the World Bank Guidance Financial Management in World Bank IPF Operations Issued and Effective February 24, 2015. 2. Key FM risks include the large number of beneficiaries, mainly the communities and some non- government entities, the extended geographic scope of Project activities, the inherent high-country fiduciary risk, the number of agreements with technical agencies during the Project implementation, and the timely selection of qualified IAs through competitive bidding process. Additional risk is related to possible high number of IAs, which may add complexity of coordination with FM unit of the KIRA (PTU-FM) project. Given these risks and the complex flow of funds, timely and reliable information might be affected. It would be required to closely manage and monitor the implementation of the Project and the appropriate use of project funds at the province level. The conclusion of the assessment was that the FM risk is assessed as Substantial. 3. Key FM mitigation measures include: (i) the handling of the Project fiduciary activities by the existing fiduciary unit of the KIRA (PTU-FM) project; (ii) the development of a project implementation manual; and (iii) the centralization of the key fiduciary responsibility within the KIRA Project FM unit; (iv) the timely recruitment of provincial coordinators and one additional accountant to strengthen the finance team aiming to intensify the supervision and monitoring of the IAs, responsible entities in implementation of Component 1 of the Project. The DGR will host a Designated Account (DA) for the Project and each IA will open a separate bank account to manage funds received as part of the Project. As such, the following mitigating measures were identified to ensure smooth implementation of Component 1: (i) the contracts between the DGR and the IAs will clearly define FM, financial reports, and audits requirements; (ii) The PIM includes procedures for selecting the IAs and defines eligibility criteria for selecting NGOs or non- government entities. Additionally, the PIM includes reporting formats, as well as auditing and disbursements arrangements to be applied to the Project; (iii) a special purpose assignment audit will be required for each IA regarding the volume of funds managed to ensure that disbursements made by the IA are eligible. The ToRs for this assignment would be included in the PIM. IAs, according to their status, comply with the Burundi regulations applicable to them, particularly in accounting, social, and fiscal matters, unless otherwise agreed with the World Bank, in line with IPF Policy guidelines, as well as eligibility criteria set forth in the PIM. Page 51 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 4. Planning and budgeting arrangements. The AWPB, along with the disbursement forecast, will be developed by the PTU-FM with input from different implementing entities at central, provincial levels as well as from non-governmental entities. Review and approval process, as well as the budget will be developed in the PIM. The quarterly IFRs will be used to monitor the execution of the AWPB. 5. Accounting arrangements. The current accounting standards in use in Burundi for ongoing World Bank-financed projects will be applicable to the proposed project. The existing integrated financial and accounting system will be used for the Project activities to generate reports such as IFRs. The Project code and chart of accounts will be developed to meet the specific needs of the Project and documented in the PIM. 6. Internal control and internal auditing arrangements. Key administrative and accounting procedures, with key internal control procedures from transaction initiation, review, approval recording, and reporting will be developed in the PIM with clear segregation of duties. Table 1.1: Risk Assessment and Mitigation Measures Risk Risk Risk-Mitigating Measures Conditions for Residual Rating Incorporated into Project Design Effectiveness Risk (Y/N) Inherent risk H S Country level. Burundi is a H The Government is committed to a N H high-risk country from the reform program that includes the fiduciary perspective. The strengthening of PFM. This project will Public Expenditure and enhance the Government’s Financial Accountability institutional capacity to adopt and use Review, PEFA (2008, 2014) as IDA FM procedures. well as the UCS reports outlined weaknesses in PFM at both central and decentralized levels. Entity level. MoH has limited H The existing KIRA Project FM unit N S capacity in managing World staffed with competent consultant will Bank–financed projects. Giving handle the project FM activities. fiduciary responsibility to the Project support to be provided to the civil servants may undermine MoH of high-level local experts in the the FM performance of the areas of FM/accounting and project. procurement. Gradual use of the Country fiduciary systems would be considered. Page 52 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Risk Risk Risk-Mitigating Measures Conditions for Residual Rating Incorporated into Project Design Effectiveness Risk (Y/N) Project level. Weak FM S KIRA PTU-FM with track record N S performance as a result of lack performance will manage the FM of competence and experience aspects of the Project. It will be of key fiduciary staff. reinforced with a recruitment of additional staff on a need basis. The project is complex with several agencies, a great A PIM (including FM procedures) will Y number of beneficiaries, etc. be developed to allow transparent while there is no FM execution of the Project. arrangement at provincial level. This may inherently place The PTU will not deal directly with the a high-risk exposure to the Communities. Implementing agencies proper use of project funds. will be recruited to do so. An internal auditor will be recruited to mitigate some related fiduciary risks resulting from the complexity of the Project. Control Risk S S Budgeting. The AWPB may not S The Project Financial Procedures N S be prepared timely and may Manual (which will be part of the PIM) not be reliable or may not will define the arrangements for reflect project needs. Risk of budgeting, budgetary control, and the cost overruns and adverse requirements for budgeting revisions. variations in expenditure could Annual detailed disbursement arise due to potential slow forecasts and budget will be required. implementation. IFRs will provide information on budgetary control and analysis of variances between actual and budgeted expenditure. Capacity- building activities may be provided to support preparation and monitoring of a reliable budget. Accounting. Poor policies and S Accounting procedures will be Y S procedures, and delays in documented in the manual of keeping reliable and auditable procedures. accounting records. The FM functions will be carried out by qualified staff. Internal Control. Weak internal S The PIM will outline procedures for Y S control system because of a internal control that will be applied lack of clarification of the roles and monitored by the Project. Also, FM and responsibilities of key supervision will contribute to mitigate players involved in project the risk relating to internal control. management. Staff well versed in World Bank FM The great numbers of players procedures is already in place and will and beneficiaries poses key be supplemented by some accountants risks. depending on the workload. Page 53 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Risk Risk Risk-Mitigating Measures Conditions for Residual Rating Incorporated into Project Design Effectiveness Risk (Y/N) An internal auditor will be recruited. Funds Flow. Risks include S Experienced staff familiar with N S delays in disbursing funds to disbursement procedures to be finance the project’s activities recruited. and delays in the replenishment of the DA. The Project will not deal directly with the beneficiaries but will contract with The Project will pay a great a selected number of government and number of beneficiaries in five non-government agencies, as well provinces. some implementation agencies Funds will be made available to the implementers to allow smooth implementation of the activities, and most payments will be made at central level. Frequent implementation Support by the bank FM Specialist if required. Celling for direct payment for contracts denominated in foreign currencies will be revised to allow more direct payments. Most expenses will be in local currency. Financial Reporting. Inaccuracy S PTU-FM team will be reinforced. N M and delays in submission of IFRs and financial statements. The existing software being used for KIRA Project will be used for the current Project. Comments provided by the World Bank during reviews of the reports will help to improve their quality. Auditing. Poor quality audit H Only qualified audit firms will be short- N S listed. Delays in submitting financial The ToRs for the auditor as well the audit reports. short list will be reviewed by the World Bank. Delays in the implementation IFR will be produced on a quarterly of audit recommendations. basis and the project financial statements will be made available by three months after the end of the year. Audit recommendations will be closely monitored during the project implementation. Page 54 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Risk Risk Risk-Mitigating Measures Conditions for Residual Rating Incorporated into Project Design Effectiveness Risk (Y/N) Governance and S (a) PIM including FM procedures Y S Accountability. Possibility of manual will be developed for the circumventing internal control, implementation of the activities of the and abuse of administrative project; (b) robust FM arrangements positions are potential risks; will be designed and their operating mis-procurement and so on, is effectiveness monitored during FM a critical issue. implementation support missions; and (c) Measures will be taken to improve transparency such as providing information on the project status to the public; (d) FM supervision will be increased if necessary OVERALL FM RISK S S Note: H = High; S = Substantial. 7. Reporting arrangement. The PTU-FM will record and report on project transactions and submit to the World Bank IFRs no later than 45 days after the end of each calendar quarter The Project will use the IFR template currently being used with KIRA project. At the end of each fiscal year, the Project will issue the Project Financial Statements (PFSs), comprising: (i) a balance sheet; (ii) a statement of Sources and Uses of Funds; (iii) accounting policies and procedures; and (iv) notes related to significant accounting policies and accounting standards adopted by management and underlying the preparation of financial statements. The reporting requirements from the IAs to the PTU will be determined in the PIM. 8. External auditing arrangement. An independent and qualified external auditor will be recruited on approved ToRs within six months after project effectiveness. The external audit will be carried out per International Standards on Auditing (ISAs) and will cover all aspects of project activities implemented and include verification of eligibility of expenditures and physical verification of goods and services acquired. Audit reports must be submitted to IDA within six months after the end of each fiscal year. The Project will comply with the World Bank disclosure policy of audit reports (for example, making them publicly available promptly after receipt of all final financial audit reports, including qualified audit reports) and disclose the report on the official website within one month after the final version is accepted. 9. Funds flow arrangements. Funds will flow from the financing account to the DA open at the Central Bank by the Government. PTU-FM and the project Coordinator will operate on the account at the Central Bank. Funds will be centralized at the PTU-FM level. Disbursement will be made to non-government agencies and other implementation agencies based on the provisions in the MoU. For government entities and project coordination at provincial level, disbursement will be centralized at the PTU level. On a case by case basis, some advances may be released to speed up the project implementation in the field. As regard to the implementing agencies (one per province), funds will be released in accordance with the provisions in the agreement between each IA and the PTU. Some UN agencies will also contract with the Government mainly for the procurement of some specific items and other activities. Funds will be released in accordance with the agreements between such agencies and the Government. Funds flow arrangements will be documented in the PIM. Page 55 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) 10. Governance and accountability. The risk of fraud and corruption within project activities is substantial, given the country context, the nature of the project and the variety of key players involved. The effective implementation of the proposed fiduciary mitigation measures should help to strengthen the control environment. There is ongoing review aiming at mainstreaming Citizen Engagement in the World Bank Portfolio in Burundi. The Project would benefit a lot from the outcome of such review. Table 1.2: FM Action Plan No. Action Due by Responsible 1 Revise the finance and administrative manual of Three months after the project effectiveness PTU-FM procedures to include the new FM structure 2 Recruit an internal auditor and one additional Three months after the project effectiveness PTU-FM accountant to support PTU-FM unit. 3 Recruit an independent audit firm for the audit of Six months after the project effectiveness PTU-FM the project financial statements, including IAs financial statements One month after the project effectiveness PTU-FM 4 At the end of the contract, the ToR of the current Three months after the project effectiveness PTU-FM FM Specialist should be revised, and this position is going to become the Head of the Finance unit and will be supervising the finance team and she will be the head of the finance unit. 11. Implementation Support Plan. Implementation support missions will be conducted over the Project’s lifetime. The Project will be supervised on a risk-based approach. Implementation support will cover but not be limited to the review of audit reports and IFRs and would include advice to the task team on all FM issues. Based on the current residual risk rating (Substantial), the Project will be supervised at least twice a year. The frequency for supervision will be adjusted over time according to the risk. Table 1.3: Implementation Support Plan FM activity Frequency Desk reviews IFR review Quarterly. Audit report review of the program Annually. Review of other relevant information such as interim Continuous as they become available. internal control systems reports On-site visits Review of overall operation of the FM system Semi-annually (implementation support mission) Monitoring of actions taken on issues highlighted in audit As needed, but at least during each implementation reports, auditors’ management letters, internal audit, and support mission. other reports Transaction reviews (if needed). As needed. Capacity-building support FM training sessions by World Bank FM team. Following the project transition and thereafter as needed. Page 56 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Disbursements 12. A DA will be opened at the Burundi Central Bank (BCB) on terms and conditions acceptable to IDA under the fiduciary responsibility of the PTU. Replenishments to the DA will be made against withdrawal applications supported by Statements of Expenditures (SOEs) or records and other documents as specified in the Disbursement Letter (DL). Upon project effectiveness, transaction-based disbursements will be used. The option to disburse against submission of quarterly unaudited IFRs (also known as report-based disbursements) could be considered subject to the quality and timeliness of the IFRs submitted to the World Bank and the overall FM performance as assessed in due course. The other methods of disbursing funds (reimbursement and direct payment) will also be available to the Project. 13. In addition to the DA, the Project will open an account denominated in BIF at a commercial bank to capture revenue resulting from the sale of bidding documents, and balances on expenses non-entirely spent. Table 1.4: Disbursement of Eligible Expenditures per Category Category Amount of the Grant Percentage of Expenditures Allocated (expressed in SDR) to be Financed (inclusive of Taxes) (1) Goods, consulting and non-consulting 21,200,000 100% services, training and operating costs (2) Emergency expenditures under Part C of 0 100% the Project (3) Refund of Preparation Advance 400,000 Amount payable pursuant to Section 2.07 (a) of the General Conditions TOTAL AMOUNT 21,600,000 Page 57 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) Figure 1.1. Flow of Funds IDA DA US$ (Central Bank managed by the PTU Good and Service providers, IAs, Government and non-Government entities, etc. on the basis of contracts, budget, MoU, etc Page 58 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ANNEX 2: Community Level Approach: Continuum of Services Adolescent / woman of childbearing age ▪ Communication for behavioral change on Sexual Reproductive Health ▪ Provision of educational services on Sexual Reproductive Health ▪ Offer FP method and promote Sayana Press at community level with CHWs ▪ Establish reference system between CHW and youth friendly health centers and vice versa ▪ Advocacy for the promotion of Sexual Reproductive Health among youth. ▪ Nutrition education focusing on micronutrient deficiencies Pregnant and Lactating women ▪ Antenatal and postnatal consultations services offered and consistent ▪ Prevention and treatment of diseases during pregnancy and in lactating period such as malaria, anemia ▪ Promotion of post-natal visits to ensure women and newborn with better nutrition and Sexual Reproductive Health services ▪ Integrate FP service in postpartum unit (maternity ward) to provide women with modern FP choices. ▪ Iron/folic acid supplementation during antenatal care ▪ Awareness of exclusive breastfeeding during antenatal care and ensure practice during the first six months ▪ Promotion of good feeding practices among pregnant and lactating women and their families Children under five ▪ Growth promotion: weighing, interpersonal communication ▪ Nutrition education for mothers / caregivers: IYCF, enriched flour production based on local products, Page 59 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) culinary demonstration ▪ Micronutrient supplementation: vitamin A, MNPs and deworming ▪ Prevention and early management of childhood illness (IMCI) ▪ Prevention and management of acute malnutrition at community level ▪ Early stimulation during the first 1,000 days Household and couples ▪ Information sharing and active communication on SRH / FP challenges ▪ Encourage and promote the participation and engagement of men on SRH and FP related activities ▪ Ensure a space of communication between care provider –head of household / couple to exchange on nutrition and FP matters ▪ Address nutrition determinants: nutrition sensitive interventions for vulnerable households Vulnerable households ▪ Community Initiatives related to agriculture and WASH ▪ Production of high nutritional value foods: kitchen gardens, poultry farming, small ruminant farming, promotion of bio-fortified varieties ▪ Capacity building for processing and preservation of high nutritional value foods ▪ Promotion of Community Led Total Sanitation ▪ Improve access to quality water in vulnerable communities ▪ Promotion of key hygiene practices Page 60 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ANNEX 3: Description of Community Nutrition interventions Focusing on the first 1,000 Days 1. The primary objective of interventions is to improve demand for and utilization of essential services known to improve nutritional status of children under-two by integrating community-based interventions related to maternal health, nutrition and early stimulation. The first 1,000 days is a window of opportunity for an integrated approach including nutrition specific and sensitive interventions (including early stimulation/parental care giving) aiming to address the key determinants of malnutrition. The interventions will build on existing and adapted community-led approaches to develop the demand-side. Engaging and empowering communities will be key to promote utilization of services and adoption of adequate behaviors for child development. 2. The first 1,000 days offer a great window of opportunity for pregnant and lactating women to be sensitized to use antenatal and post-natal services and will benefit from counseling on behaviors and feeding practices that promote good health and nutrition during pregnancy. 3. Children under two related services will be on child growth promotion and cognitive development, infant and young child feeding practices, management of childhood illness and acute malnutrition at community level. Activities include monthly evaluation of growth of children under-two years of age with counseling feedback to mothers, early stimulation, infant and young child feeding practices allowing mothers to discuss child health and reproductive health matters while sharing local recipes for complementary foods based on local products, micronutrient supplementation as well as community management of acute malnutrition. 4. The IAs who will be selected to implement the Project at the province level will facilitate the interventions’ implementation. Within the six targeted provinces, the Project IAs will implement the Project in up to 620 collines and 1933 sub- collines. Activities at this level will be carried out by community actors, such as CHWs, MLs and agricultural community actors. The IA’s teams will ensure oversight and supervision of those community actors. The communities at village level will be asked: to identify and enroll the MLs who are key service delivery; facilitate the services delivery (affecting a suitable place for activities); support the delivery system actors to resolve the various difficulties. A community-based working environment will be built around Community nutrition workers (MLs) who will deliver services and support the implementation process. Building on the FARN experience (Hearth Model), community- nutrition sites will be set up to be the convening point for the different activities throughout the targeted collines. In order to ensure quality in service delivery a number of norms will be followed in managing the nutrition sites: a ML will cover not more than 75 children under two for growth promotion and 150 children under five for acute malnutrition screening; information and education groups composed by mothers of children under five and women of reproductive age will be formed and will not exceed 25 members; growth promotion groups for children under two will not exceed 25 members. The IAs will organize the service delivery following these norms. Within the community-nutrition sites, community workers (ML) will be trained to monthly monitor the growth of the children under-two following the WHO protocol. An adequate weight gain is foreseen each month for children during their first two years of life pushing the ML to conduct interpersonal communication with mothers and caregivers. This dialogue will be the cornerstone for optimizing the child’s growth because of the decisions that will be taken regarding all the different types of caring needed by the child for the next month. From that dialogue, different recommendations can be raised related to feeding practices, hygiene and sanitation, child’s social Page 61 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) environment etc. Growth Promotion of children includes HVs for children who are absent or who did not have an adequate growth over two consecutive months without being severely malnourished. Children suffering from severe malnutrition will be referred to health structures for an adequate medical care. The community workers will be provided with comprehensive and adapted communication tools (counseling cards, aide-memoire, picture box, etc.) The technical capacities of the community workers to communicate are very important for the expected behavior changes and social transformation. The IAs will therefore develop strong training programs and adopt efficient supervision methods in order to continuously improve the performances at the community level. 5. The community workers will also be trained to reinforce mothers and caregivers’ capacities to stimulate children during their first 1 000 days. The promoted care practices for early stimulation will be on simple attitudes during pregnancy, feeding and playing moments that contribute to child development and well-being. Children under-two will also benefit from micronutrient supplementation activities with vitamin A and micronutrient powders. ML will promote C-IMCI behaviors emphasizing on exclusive breastfeeding, complementary feeding, food diversification, early treatment of childhood illness (diarrhea, malaria, respiratory diseases, etc.). ML will also promote birth spacing and FP as nutrition sites offer a good opportunity to reach mothers of children under-two. The Sayana Press method will be particularly promoted and a counseling and referral system will be built with CHWs. Cooking demonstration activities will be organized in the nutrition sites and will offer privileged moments of discussion on child feeding, local recipes and feeding community practices. Quarterly campaigns for active screening of acute malnutrition will be organized and malnourished children will be managed at community and health center levels according to the national protocol. The community-based approach for acute malnutrition management will require the enhancement of capacities for communities and health centers to ensure an effective management of moderate cases at community level and a functional referral system to health structures for severe cases. 6. The existing CHW will be the entry point allowing the expansion of the community-based service delivery platform with high impact interventions on pregnant and lactating women as well as children under-two. The health system (health center level) will support the community-level services delivery by providing training and supervision to the community actors. 7. The Project will promote the participatory approach which will require innovative methods to ensure community involvement and ownership. The IAs will be asked to propose sound strategies for sustainable community engagement. 8. CSC will be set up on each colline (commune subdivision) building on community dynamics with representation of different segments of the community. The CSC will support and oversee service delivery under the Project by: supporting the planning process for the different activities at the community level; organizing periodic restitutions to the stakeholders to support continuous performance in the service delivery; ensuring community mobilization and participation in the different activities. 9. The nutrition sensitive interventions will be built on the community-based approach targeting the most vulnerable. The nutrition sensitive interventions will focus on household food security and access to safe water and sanitation and will be supported through community-driven projects. The interventions will be implemented with the support of contracted IAs. The community-driven projects will be critical to Page 62 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ensure resilience and sustainability of the above proposed community level approach to address stunting. CDD approaches will be used by IAs to ensure community engagement and development of adapted grants. The CDD approach will ensure transparency in a key process like the targeting of the most vulnerable households. The IAs will be asked to conduct rigorous methods for a participatory community-based targeting and an effective control to avoid leakage, elite bias or manipulation. Typical expenditures in this component refer to community grants and will require implementation support from local actors (Community steering committees, local authorities, beneficiaries). This component will rely on citizens’ engagement: engagement of communities will allow identifying community initiatives to be supported by the Project which will enhance capacities of households in general, and women in particular, to produce, buy and provide adequate food for the household, notably for children and women. Community nutrition initiatives will be defined according to community needs with attention given to strategies promoted by the GoB, and that have been piloted in country with external funding, such as: kitchen gardens, small livestock husbandry, use of improved seed varieties and animal races, food conservation and transformation technologies. 10. The promotion of hygiene of water sources at the community level will help to prevent diarrhea among children under-five. At the household level, the Project will focus on promoting the use of potable and clean water, supporting the most vulnerable households with latrines, hand washing and water purification kits. The ending open defecation strategy is the key strategy for behavior change at the community level. The most vulnerable households with children under-five will be targeted in a participatory approach to ensure inclusion and transparency. 11. In the six targeted provinces, the nutrition interventions will allow to reach 36 communes, 620 collines (coverage of 70 percent), 1933 sub- collines (coverage of 50 percent) at varying levels depending on the target groups as presented below (table 3.1). Table 3.1: Project beneficiaries Target group Level of coverage, year 5 Children under two 76,000 (30 percent in targeted communes) Children under five 305,000 (50 percent in targeted communes) Vulnerable households 38,000 (7 percent in targeted communes) Page 63 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ANNEX 4: Intervention Framework for Family Planning Interventions Page 64 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ANNEX 5: Roles and Responsibilities for Project Implementation CHW/TPS and ML ▪ Organize weighing sessions, interpersonal communication, early stimulation ▪ Organize active screening for acute malnutrition ▪ Counselling and FP service, promotion and provision of services ▪ Micronutrient supplementation activities ▪ Pregnancy test ▪ Organize educational and social mobilization for nutrition and FP activities ▪ Provide HVs to beneficiaries under nutrition and FP intervention ▪ Prepare and submit periodic activity reports as required Community Steering Committee ▪ Pilot the process of selecting ML / peers ▪ Manage the choice of sites for the delivery of services ▪ Analyse and approve the action plan at site level ▪ Support the organization of social mobilizations ▪ Analyse and approve the monthly report of CHW / TPS and ML ▪ Support CHW and ML in ongoing management of their performance ▪ Community monitoring of activities ▪ Support the process of selecting vulnerable households Implementing Agency ▪ Elaborate the province's interventions according to Project’s orientations ▪ Sign with the MoH a contract for the technical and financial execution of the Project financed by Nkuriza at provincial level Page 65 of 66 The World Bank Investing in Early Years and Fertility in Burundi (NKURIZA) (P165253) ▪ Facilitate the establishment of community steering committees and the selection of MLs ▪ Ensure, in collaboration with the deconcentrated structures, the training of community actors ▪ Accompany community stakeholders in micro-planning activities ▪ Provide formative supervision of community actors in collaboration with deconcentrated services ▪ Prepare and submit provincial project activity reports to the technical unit at agreed frequency ▪ Present the progress of the Project at commune and provincial levels Provincial Level ▪ Support the selection process of implementing agencies ▪ Support geographic targeting area and share basis of validation process ▪ Support IA in Project design ▪ Contribute to the annual action plan of the Project ▪ Support mobilization of actors at provincial level and below ▪ Participate in review of Project activities Page 66 of 66