FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: PAD3858
INTERNATIONAL DEVELOPMENT ASSOCIATION
PROJECT APPRAISAL DOCUMENT ON A PROPOSED INTERNATIONAL DEVELOPMENT ASSOCIATION CREDIT
IN THE AMOUNT OF EUR 13.1 MILLION
(US$14.25 MILLION EQUIVALENT) Public Disclosure Authorized
TO
THE REPUBLIC OF RWANDA
FOR THE RWANDA COVID-19 EMERGENCY RESPONSE PROJECT
UNDER THE COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PROGRAM (SPRP)
Public Disclosure Authorized
USING THE MULTIPHASE PROGRAMMATIC APPROACH (MPA) WITH A FINANCING ENVELOPE OF US$2.7 BILLION IBRD AND $1.3 BILLION FROM IDA CRISIS RESPONSE WINDOW
APPROVED BY THE RVP ON APRIL 7, 2020
Health, Nutrition & Population Global Practice Africa Region
Public Disclosure Authorized 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 {Mar 25, 2020})
Rwandan Franc Currency Unit = (RwF) US$1 (end Feb 909.1 RwF = 2020) US$ 1 = Eur 0.913
FISCAL YEAR July 1 – June 30
Regional Vice President: Hafez M. H. Ghanem Country Director: Carlos Felipe Jaramillo Regional Director: Dena Ringold Practice Manager: Ernest E. Massiah Task Team Leader(s): Miriam Schneidman, Naoko Ohno
The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
ABBREVIATIONS AND ACRONYMS
BFP Bank Facilitated Procurement COVID-19 Coronavirus Disease CPF Country Partnership Framework ES Environment and Social ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environmental and Social Management Framework FM Financial management GRS Grievance Redress Service IBRD International Bank for Reconstruction and Development IDA International Development Association IFRs International Financial Reporting Standards JEE Joint External Evaluation MPA Multiphase Programmatic Approach NEPRCC National Epidemic Preparedness & Response Committee OPCS Operations Policy and Country Services PAD Project Appraisal Document PDO Project Development Objective PPSD Project Procurement Strategy for Development PRAMS Procurement Risk Assessment and Management System RBC Rwanda Biomedical Center RCCE Risk Communication and Community Engagement RfQ Request for Quotations SARS Severe Acute Respiratory Syndrome SEP Stakeholders Engagement Plan SOEs Statements of Expenditures SPIU Single Project Implementation Unit SPRP Strategic Preparedness and Response Program SPRP Stunting Prevention and Reduction Project STEP Systematic tracking of Exchanges in Procurement WB World Bank WHO World Health Organization
The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
TABLE OF CONTENTS DATASHEET ...... 1 I. PROGRAM CONTEXT ...... 7 A. MPA Program Context ...... 7 B. Updated MPA Program Framework ...... 8 C. Learning Agenda ...... 8 II. CONTEXT AND RELEVANCE ...... 9 A. Country Context ...... 9 B. Sectoral and Institutional Context ...... 10 C. Relevance to Higher Level Objectives ...... 10 III. PROJECT DESCRIPTION ...... 12 A. Development Objectives ...... 12 B. Project Components ...... 13 C. Results Chain ...... 14 D. Project Beneficiaries ...... 15 IV. IMPLEMENTATION ARRANGEMENTS ...... 15 A. Institutional and Implementation Arrangements ...... 15 B. Results Monitoring and Evaluation Arrangements ...... 16 C. Sustainability ...... 16 V. PROJECT APPRAISAL SUMMARY ...... 16 A. Technical, Economic and Financial Analysis...... 17 B. Fiduciary ...... 18 C. Legal Operational Policies ...... 24 D. Environmental and Social Standards ...... 24 VI. GRIEVANCE REDRESS SERVICES ...... 26 VII. KEY RISKS ...... 27 VIII. RESULTS FRAMEWORK AND MONITORING ...... 30 ANNEX 1: Project Costs ...... 35 ANNEX 2: Rwanda JEE Scores ...... 36
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
DATASHEET
BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name
Rwanda Rwanda COVID-19 Emergency Response Project
Project ID Financing Instrument Environmental and Social Risk Classification
Investment Project P173855 Substantial 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 Project Approval Expected Project Closing Expected Program Closing Date Date Date
15-Apr-2020 30-Jun-2022 31-Mar-2025
Bank/IFC Collaboration No
MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness
MPA Financing Data (US$, Millions) Financing
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
MPA Program Financing Envelope 4,119.65
with an additional request to IBRD 1.00
Proposed Project Development Objective(s) The objective of the Project is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in the Republic of Rwanda.
Components
Component Name Cost (US$, millions)
Component 1. Case Detection, Confirmation and Contact Tracing 5,900,000.00
Component 2: Public Health Measures and Clinical Care Capacity 8,000,000.00
Component 3. Implementation Management and Monitoring and Evaluation 350,000.00
Component 4. Contingency Emergency Response Component (CERC) 0.00
Organizations
Borrower: Ministry of Finance (MINECOFIN)
Implementing Agency: Rwanda Biomedical Center
MPA FINANCING DETAILS (US$, Millions)
MPA FINA NCING DETAILS (US$, Millions) Approved Board Approved MPA Financing Envelope: 4,118.65
MPA Program Financing Envelope: 4,119.65
of which Bank Financing (IBRD): 2,763.80
of which Bank Financing (IDA): 1,355.85
of which other financing sources: 0.00
PROJECT FINANCING DATA (US$, Millions) FIN_SUMM_NEW
SUMMARY-NewFin1
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Total Project Cost 14.25
Total Financing 14.25
of which IBRD/IDA 14.25
Financing Gap 0.00
DETAILS-NewFinEnh1
World Bank Group Financing
International Development Association (IDA) 14.25
IDA Credit 14.25
IDA Resources (in US$, Millions)
Credit Amount Grant Amount Guarantee Amount Total Amount
Rwanda 14.25 0.00 0.00 14.25
National PBA 4.75 0.00 0.00 4.75 Crisis Response Window (CRW) 9.50 0.00 0.00 9.50
Total 14.25 0.00 0.00 14.25
Expected Disbursements (in US$, Millions)
WB Fiscal 2020 2021 2022 Year Annual 5.70 6.00 2.55
Cumulative 5.70 11.70 14.25
INSTITUTIONAL DATA
Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks
SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT)
Risk Category Rating
1. Political and Governance ⚫ Low
2. Macroeconomic ⚫ Substantial
3. Sector Strategies and Policies ⚫ Moderate
4. Technical Design of Project or Program ⚫ Moderate
5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial
6. Fiduciary ⚫ Substantial
7. Environment and Social ⚫ Substantial
8. Stakeholders ⚫ Moderate
9. Other
10. Overall ⚫ Substantial
Overall MPA Program Risk ⚫ High
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
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Have these been approved by Bank management? [✓] Yes [ ] No
Is approval for any policy waiver sought from the Board? [ ] Yes [✓] No
Environmental and Social Standards Relevance Given its Context at the Time of Appraisal
E & S Standards Relevance
Assessment and Management of Environmental and Social Risks and Impacts Relevant
Stakeholder Engagement and Information Disclosure Relevant
Labor and Working Conditions Relevant
Resource Efficiency and Pollution Prevention and Management Relevant
Community Health and Safety Relevant
Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant
Biodiversity Conservation and Sustainable Management of Living Natural Resources Not Currently Relevant
Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Not Currently Relevant Communities Cultural Heritage Not Currently Relevant
Financial Intermediaries Not Currently Relevant
NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS).
Legal Covenants
Conditions
Type Description Disbursement FA Schedule 2, Section III, B 1 (a): Notwithstanding the provisions of Part A above, no withdrawal shall be made for:
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
(a) payments made prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed Seven Million Eight Hundred Sixty Thousand Euro (€ 7,860,000) may be made for payments made prior to this date but on or after January 1, 2020, for Eligible Expenditures under Category (1);
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
I. PROGRAM CONTEXT
1. This Project Appraisal Document (PAD) describes the emergency response to Republic of Rwanda under the COVID-19 Strategic Preparedness And Response Program (SPRP) using the Multiphase Programmatic Approach (MPA), approved by the World Bank’s Board of Executive Directors on April 2nd, 2020 (P173789) with an overall Program financing envelope of International Development Association (IDA) US$1.3 billion and of International Bank for Reconstruction and Development (IBRD) US$2.7 billion.1
A. MPA Program Context
2. An outbreak of the coronavirus disease (COVID-19) caused by the 2019 novel coronavirus (SARS-CoV-2) has been spreading rapidly across the world since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China. Since the beginning of March 2020, the number of cases outside China has increased thirteenfold and the number of affected countries has tripled. On March 11, 2020, the World Health Organization (WHO) declared a global pandemic as the coronavirus rapidly spreads across the world. As of April 3, 2020, the outbreak has resulted in an estimated 1,041,126 cases and 55, 132 deaths in 181 countries.
3. COVID-19 is one of several emerging infectious diseases (EID) outbreaks in recent decades that have emerged from animals in contact with humans, resulting in major outbreaks with significant public health and economic impacts. The last moderately severe influenza pandemics were in 1957 and 1968; each killed more than a million people around the world. Although countries are now far more prepared than in the past, the world is also far more interconnected, and many more people today have behavior risk factors such as tobacco use2 and pre-existing chronic health problems that make viral respiratory infections particularly dangerous3. With COVID-19, scientists are still trying to understand the full picture of the disease symptoms and severity. Reported symptoms in patients have varied from mild to severe, and can include fever, cough and shortness of breath. In general, studies of hospitalized patients have found that about 83% to 98% of patients develop a fever, 76% to 82% develop a dry cough and 11% to 44% develop fatigue or muscle aches4. Other symptoms, including headache, sore throat, abdominal pain, and diarrhea, have been reported, but are less common. While 3.7% of the people worldwide confirmed as having been infected have died, WHO has been careful not to describe that as a mortality rate or death rate. This is because in an unfolding epidemic it can be misleading to look simply at the estimate of deaths divided by cases so far. Hence, given that the actual prevalence of COVID-19 infection remains unknown in most countries, it poses unparalleled challenges with respect to global containment and mitigation. These issues reinforce the need to strengthen the response to COVID-19 across all IDA/IBRD countries to minimize the global risk and impact posed by this disease.
4. This project is prepared under the global framework of the World Bank COVID-19 Response financed under the Fast Track COVID-19 Facility (FCTF).
1 P173789: http://operationsportal.worldbank.org/secure/P173789/home 2 Marquez, PV. 2020. “Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China.” http://www.pvmarquez.com/Covid-19 3 Fauci, AS, Lane, C, and Redfield, RR. 2020. “Covid-19 — Navigating the Uncharted.” New Eng J of Medicine, DOI: 10.1056/NEJMe2002387 4 Del Rio, C. and Malani, PN. 2020. “COVID-19—New Insights on a Rapidly Changing Epidemic.” JAMA, doi:10.1001/jama.2020.3072
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
B. Updated MPA Program Framework
5. Table-1 provides an updated overall MPA Program framework, including the proposed US$14.25 million project for the Republic of Rwanda. 5
Table 1. MPA Program Framework Estimated Estimated Estimated Estimated Estimated Environme Sequential or Phase’s IPF, DPF IBRD IDA Other Phase # Project ID Approval ntal & Simultaneous Proposed DO* or PforR Amount Amount Amount Date Social Risk ($ million) ($ million) ($ million) Rating To prevent, detect, and respond to the threat posed by COVID-19 and 1 173855 Simultaneous strengthen IPF - $14.25 - 4/9/2020 Substantial national systems for public health preparedness in Rwanda.
6. All projects under SPRP are assessed for ESF risk classification following the Bank procedures and the flexibility provided for COVID-19 operations.
C. Learning Agenda
7. The country project under the MPA Program will support adaptive learning throughout the implementation, as well as from international organizations including WHO, IMF, CDC, UNICEF, and others. The global MPA aims to support the following activities which will also benefit Rwanda through cross-country learning: a. Forecasting: modeling the progression of the pandemic, both in terms of new cases and deaths, as well as the economic impact of disease outbreaks under different scenarios. b. Technical: Cost and effectiveness assessments of prevention and preparedness activities; research may be financed for the re-purposing of existing anti-viral drugs and development and testing of new antiviral drugs and vaccines. c. Supply chain approaches: Assessments may be financed on options for timely distribution of medicines and other medical supplies. d. Social behaviors: Assessments on the compliance and impact of social distancing measures under different contexts.
8. Rwanda has a strong track record of using IT solutions to improve service delivery and will be exploring several key digital solutions and data analytical tools that will improve the management and containment of the COVID-19 response and future outbreaks. Several innovations are under discussion and will be rolled out as part of the COVID-19 learning agenda that are unique and can be replicated in other countries,
5 Rwanda is exceeding its FTCF allocation by 50 prevent, and the exceeded amount of $4.75 million which is within the 50 percent maximum excess utilization limit will be deducted from its FY21 Performance-Based Allocation envelope.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
including: (i) development of digitally enabled solutions, such as mobile apps for sending out health messages; digital maps that allow to visualize the spread of the infectious disease in real time, call centers providing remote advice specific to the COVID-19 pandemic, data analytics dashboards to allow for visualization of identified cases; (ii) establishment of telemedicine/telehealth capability to allow for suspected cases to be assessed without the need for physical movement by patients; and (iii) provision of internet connectivity to make healthcare consultations more accessible to remote communities.
II. CONTEXT AND RELEVANCE
A. Country Context
9. The coronavirus pandemic poses serious economic and public health threats to Rwanda. Rwanda was in the middle of an economic boom prior to the COVID-19 pandemic. Economic growth exceeded 10 percent in 2019 driven mostly by large public investments for implementation of the National Strategy of Transformation. Strong growth was expected to continue in 2020. The global pandemic has disrupted international flows of goods and services with significant spillovers to the broader global economy. Exports and tourism are taking a strong hit amid disruption in international trade and travel. Rwanda is already feeling mounting balance of payment and fiscal pressures. This could negatively impact the provision of public health services with respect to COVID-19 response and preparedness capacity as well as adversely affect the provision of other essential health service delivery in Rwanda, as healthcare workers and fiscal resources are redirected to the emergency response.
10. Rwanda is at high risk of transmission of the coronavirus and has already about 50 confirmed cases. Rwanda has a vibrant national aviation carrier (which is temporarily grounded) with a wide and expanding number of flights to several continents, including a direct flight to China and to other countries most affected by the ongoing global pandemic. In fact, most reported cases to date are individuals who arrived or transited through the Kigali airport. Likewise, the risk of community transmission remains substantial given that infected individuals can be asymptomatic and transmit the disease; the country has a high population density; and a sizable proportion of the population in Kigali lives in unplanned settlements. 6
11. The government of Rwanda has demonstrated high-level leadership and taken swift action to tackle the risks associated with the ongoing pandemic and bend the curb on COVID-19. The effort to contain the potential spread of COVID-19 is led by the Office of the Prime Minister under the National Epidemic Preparedness & Response Committee (NEPRCC), in collaboration with the Ministry of Health, Ministry of Local Government and Ministry of Foreign Affairs. The government put in place a mandatory national lock down policy on March 21, 2020 which was in effect for two weeks and extended for another two weeks. This includes border closings and stringent social distancing policies (e.g. closing schools, churches, and bars; postponing conferences, mandating home-based work) and banning motorcycle drivers from carrying passengers. All commercial passenger flights to and from Rwanda were suspended on March 20, 2020.
12. The government has taken several other complementary actions to enhance preparedness. Authorities have conducted a preliminary risk assessment which highlighted key risk factors for importation of the
6About 63 percent of Kigali’s settlements are considered unplanned, characterized by limited access to basic infrastructure and poor living conditions which can serve as the breeding ground for the spread of diseases.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
coronavirus into the country. The Ministry of Health has expeditiously activated its Emergency Operation Centre and has established a Coronavirus National Taskforce to coordinate the national response. Rwanda has strengthened surveillance at all entry points; placed a high alert among health care workers and strengthened community-based disease surveillance. The government is promoting handwashing best practices with President Kagame taking part in the ‘Safe Hands’ challenge to encourage the public to emulate these behaviors. The country has recently benefited from a grant contribution of testing kits from Jack Ma Foundation that will help in quickly initiating testing with distribution through the Africa CDC which is managing the continental COVID-19 response and stockpiling of critical commodities.
B. Sectoral and Institutional Context
13. Rwanda has a relatively strong public health system and a sound track record of protecting the health and well-being of the population, but many gaps persist. The government has established disease outbreak and preparedness structures and adopted appropriate policies and strategies to respond swiftly to various outbreaks in the past, minimizing case fatality rates. The Ministry of Health has a well-established disease surveillance department and aims to adhere to the International Health Regulations (IHR), uses the Integrated Disease Surveillance and Response (IDSR) system and sets the policy and strategic guidance for all disease outbreaks to ensure prompt detection and reporting. The Rwanda Biomedical Center (RBC) has the mandate to ensure effective implementation of disease outbreak and preparedness activities. The Epidemic Surveillance and Response Division plays the primary role in preventing and controlling epidemics and other public health emergencies.7 Despite progress made in strengthening disease outbreak response and preparedness capacity, key gaps persist as captured in the Joint External Evaluation (JEE) with an overall score of 58 percent and relatively low scores on several key areas that will be supported under the proposed project, such as infection prevention and control; risk communication; and PoE public health response capacity (Annex II).
14. The government has elaborated a coronavirus national plan at record speed and in a consultative manner. The Coronavirus Disease 19 National Preparedness and Response Plan is fully in line with the World Health Organization (WHO) global guidance and includes all recommended pillars. The Plan is consistent with the Joint Continental Strategy on COVID-19, as agreed with African Union Ministers of Health in February 2020 under the auspices of the Africa CDC, a flagship institution established by the African Union with a continental mandate for infectious disease surveillance and control. The plan is comprehensive in nature and covers the full range of interventions to support the coronavirus response and preparedness efforts. The overriding goal is to prioritize prompt case detection, infection control, risk communication and community engagement, point of entry screening, laboratory confirmation, quarantine and isolation for effective case management. The country’s strong track record managing other outbreaks augurs well for addressing the coronavirus response and preparedness efforts.
C. Relevance to Higher Level Objectives
15. The project is aligned with World Bank Group strategic priorities, particularly the WBG’s mission to end
7The Epidemic Surveillance and Response Division includes the: (i) Avian Influenza and Highly Pathogenic Diseases, Food and Waterborne Diseases, and Outbreak Preparedness and Response; (ii) National Reference Laboratory which ensures the provision of quality laboratory diagnostics; and (iii) Rwanda Health Communication Centre which is responsible for disseminating health messages to the general public and promoting healthy behaviors.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
extreme poverty and boost shared prosperity. The Program is focused on preparedness which is also critical to achieving Universal Health Coverage. It is also aligned with the World Bank’s support for national plans and global commitments to strengthen pandemic preparedness through three key actions under Preparedness: (i) improving national preparedness plans including organizational structure of the government; promoting adherence to the International Health Regulations (IHR); and utilizing international framework for monitoring and evaluation of IHR. The economic rationale for investing in the MPA interventions is strong, given that success can reduce the economic burden suffered both by individuals and countries. The project complements both WBG and development partner investments in health systems strengthening, disease control and surveillance, attention to changing individual and institutional behavior, and citizen engagement. Further, as part of the proposed IDA19 commitments, the World Bank is committed to “support at least 25 IDA countries to implement pandemic preparedness plans through interventions (including strengthening institutional capacity, technical assistance, lending and investment).” The project contributes to the implementation of IHR (2005), Integrated Disease Surveillance and Response (IDSR), and the OIE international standards, the Global Health Security Agenda, the Paris Climate Agreement, the attainment of Universal Health Coverage and of the Sustainable Development Goals (SDG), and the promotion of a One Health approach.
16. The WBG remains committed to providing a fast and flexible response to the COVID-19 epidemic, utilizing all WBG operational and policy instruments and working in close partnership with government and other agencies. Grounded in One-Health, which provides for an integrated approach across sectors and disciplines, the proposed WBG response to COVID-19 will include emergency financing, policy advice, and technical assistance, building on existing instruments to support IDA/IBRD-eligible countries in addressing the health sector and broader development impacts of COVID-19. The WBG COVID-19 response will be anchored in the WHO’s COVID-19 global Strategic Preparedness and Response Plan (SPRP) outlining the public health measures for all countries to prepare for and respond to COVID-9 and sustain their efforts to prevent future outbreaks of emerging infectious diseases.
17. The proposed project is aligned with the World Bank’s current Country Partnership Framework (FY2014- FY2020) and the next draft Country Partnership Framework (CPF) for Rwanda8. The CPF has a major focus on human capital development, including protecting the well-being of the population. The proposed project is also well aligned with Rwanda’s National Strategy for Transformation, which aims to strengthen disease prevention awareness and reduce the spread of communicable diseases. The project fills critical gaps in the World Bank’s support, as the current portfolio focuses on combating chronic malnutrition and does not include support for disease surveillance and response to global pandemics such as COVID-19. The project is also fully aligned with the Government’s health sector strategies, including the Health Sector Strategic Plan 4 (HSSP4 2018-2024), which under the health security chapter, underscores the importance of preventing and controlling epidemic diseases and other public health threats through a sustainable, effective and efficient national epidemiological surveillance, response and recovery system. The project leverages on capacity built under the first phase of the Bank-funded regional East Africa Public Health Laboratory Networking Project which supported the construction of a network of state-of-the art district laboratories in Rwanda to enhance laboratory confirmation of pathogens; and strengthened disease outbreak preparedness capacity, including participation in the East Africa Integrated Disease Surveillance Network. Rwanda’s experience with laboratory and disease surveillance networks can now be leveraged and further supported by the Africa CDC which aims to support the establishment of the Regional Integrated
8 FY2014-2020; Report Number: 87025-RW. The CPF 2021-2026 is being finalized.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Disease Surveillance and Laboratory Networks (including in East Africa).9
III. PROJECT DESCRIPTION
18. This project was selected for COVID-19 financing because of the high-level political commitment in Rwanda to protect public health, invest early, and avert the high socio-economic costs associated with disease outbreaks and global pandemics. The objectives and components are fully aligned with the COVID-19 Fast Track Facility guidelines. The project is expected to complement activities to be supported by the government and other development partners. 10 The focus is on supporting the COVID-19 National Preparedness and Response Plan, assisting Rwanda to respond swiftly to confirmed cases. The project is also aligned with the guiding principles for the COVID-19 national plan, such as: (i) recognizing that prevention and control of COVID-19 is a global public good with spillover effects for all countries, requiring strong financial contributions at the national and international level (which aligns well with the WBG coronavirus facility); (ii) underscoring the need to leverage existing institutions, draw on scientific evidence, and adopt innovative digital solutions; and (iii) acknowledging the importance of strengthening overall national disease prevention and emergency response capacity.
A. Development Objectives
19. The Project objectives are aligned to the results chain of the COVID-19 Strategic Preparedness and Response Program (SPRP).
20. Project DO statement: The Project Development Objective (PDO) is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Rwanda.
21. The specific objectives of the project, aligned with the national COVID-19 Plan, are to: (i) strengthen case detection and confirmation and conduct contact tracing; (ii) improve clinical care capacity; (iii) raise public awareness and promote community engagement; and (iv) bolster coordination, planning, logistical support, and reporting. While the focus is on the coronavirus response and preparedness, the activities to be supported are expected to have cross-cutting benefits for addressing other disease outbreaks.
22. PDO level indicators: The PDO will be monitored through the following PDO level outcome indicators:
PDO Indicators: • Proportion of suspected cases of COVID-19 reported and investigated based on national guidelines • Number of designated laboratories with COVID-19 diagnostic capacity (equipment, test kits, reagents) • Proportion of targeted healthcare facilities with isolation capacity
9 The Regional Integrated Disease Surveillance and Laboratory Networks (RISLNET) will support the operationalization of the Eastern Africa Regional Collaboration Center (RCC) as has been done for other sub-regions with Ethiopia and Zambia serving as RCCs. 10 To date, the activities identified for WB financing under this emergency operation constitute the main external commitments. Discussions are underway with other development partners to identify other sources of financing for the US$26 million national COVID-19 Plan. For example, USAID plans on supporting community health workers to conduct outreach and disease surveillance.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Intermediate Indicators: • Proportion of targeted healthcare facilities with clinical capacity for COVID-19 patients • Number of health staff trained in infection prevention and control • Number of laboratory staff trained to conduct COVID-19 diagnosis
B. Project Components
23. The project comprises three mutually complementary components that focus on the immediate response, and includes a range of evidence-based interventions:
24. Component 1. Case Detection, Confirmation and Contact Tracing (US$5.9 million) This component will support the government to enhance disease surveillance, improve sample collection and ensure rapid laboratory confirmed diagnoses to promptly detect all potential COVID-19 cases and to carry out contact tracing to quickly contain COVID-19. The focus will be on: (i) screening travelers at 31 Ports of Entry (Kigali airport and cross-border areas once the current restrictions are lifted); as well as priority communities and targeted health facilities; (ii) diagnosing cases and referring them for treatment as needed; (iii) carrying out contact tracing to minimize risk of transmission; (vi) conducting risk assessments to identify hot spot areas of transmission, including digital maps that can help visualize transmission; and (v) carrying out multi- sectoral simulation exercises for COVID-19 and other disease outbreaks. To this end, the project will fund: (i) medical supplies and equipment (e.g. thermo scanners; test kits; drugs; lab equipment and supplies, personal protective equipment); (ii) training and capacity building for frontline workers; and (iii) operating costs for Rapid Response Teams and recruitment of additional personnel.
25. Component 2: Public Health Measures and Clinical Care Capacity (US$8.0 million) This component will fund the reinforcement of public health policies and measures and the establishment of critical clinical care capacity at a network of public sector district hospitals, promoting digital solutions to be explored during implementation. The main public health policies to be enforced include: social distancing measures (e.g. border closings; work-at-home policies; restricting public gatherings); personal hygiene promotion, including handwashing and proper cooking; and risk communication and community engagement in line with WHO guidance and using local channels (e.g. national radio and other IT related tools) to disseminate messages about the risks associated with COVID-19 and applying innovative digital solutions such as mobile apps for sending out messages. With respect to clinical care, the project will support the government to establish isolation capacity at a selected number of national and district hospitals which would be responsible for triaging and treating COVID-19 cases and would benefit from video conferencing equipment to establish telemedicine capacity. The goal is to rehabilitate/adapt existing structures, and leverage isolation units established for other infectious diseases to make efficient use of costly structures. To support providers to triage and provide urgently needed care to sick patients, the project will ensure health personnel are well protected and work in a safe and secure environment. To this end, the project will fund: (i) production and dissemination of communication materials (including in digital form) and organization of national and local campaigns to raise awareness as well as establishment of data analytics capability to improve targeting and measure effectiveness; (ii) medical and laboratory equipment and supplies and waste management equipment and supplies and video conferencing equipment for telemedicine; (iii) minor civil works (mainly refurbishments); and (iv) operating costs, including recruitment of additional clinical personnel.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
26. Component 3. Implementation Management and Monitoring & Evaluation (US$.35 million) The third component will support program coordination, management and monitoring; operational support and logistics; and project management. This will include support for the COVID-19 Incident Management System Coordination Structure; operational reviews to assess implementation progress and adjust operational plans; and provide logistical support. To this end, the project will fund: (i) technical assistance; (ii) vehicles to facilitate supervision; and (iii) operating costs.
27. Component 4: Contingency Emergency Response Component (CERC) A zero cost CERC component will provide support for future emergency responses. Following an eligible crisis or event, clients may request the Bank to re-allocate project funds to support an additional emergency response. This component would draw from the uncommitted credit resources under the project from other project components to cover emergency response. CERCs can be activated without needing to first restructure the original project, thus supporting rapid implementation. To facilitate a rapid response, formal restructuring is deferred to within three months after the CERC is activated.
Table 2: Project Costs, by Component and Sub-Component
IDA Project Components and Activities % of Total Financing Component 1: Case Detection, Confirmation and Contact 5.9 41.0 Tracing -Disease Surveillance, RRTs and case investigation 2.2 -Laboratory Capacity and Specimen Transport 2.8 -Points of Entry 0.9
Component 2: Public Health Measures and Clinical Care 8.0 56.0 Capacity -Risk Communication and Community Engagement 0.4 -Case management/specialized units/lab capacity 5.8 -Infection Prevention and Control 1.8 .35 3.0 Component 3: Implementation Management and M&E
-Country level coordination, planning, and monitoring .20 -Project Management .15
Component 4: CERC 0
Total Costs 14.25 100.0
C. Results Chain
28. Swift detection of an outbreak and rapid emergency response can reduce avoidable mortality and morbidity and prevent the high socio-economic costs associated with disease outbreaks. Delays in the mobilization of financing and inadequate coordination result in unnecessary casualties and significant socioeconomic costs. By focusing on rapid containment, diagnosis and treatment of patients, the project
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
aims to control the outbreak and limit socioeconomic losses. As shown in the Project Results Chain (Figure 1), the project will support urgent response activities to strengthen the supply chain, clinical care and laboratory capacity; bolster human resources; and enhance awareness. Together, these activities will improve the timely detection and response to COVID-19 and other infectious disease outbreaks.
Figure 1: Project Results Chain
D. Project Beneficiaries
29. The main project beneficiaries will be healthcare workers and port of entry officials; emergency personnel; and infected people. Other beneficiaries will include the general population that will benefit from improved awareness and enhanced public health measures.
IV. IMPLEMENTATION ARRANGEMENTS
A. Institutional and Implementation Arrangements
30. The institutional, implementation and coordination arrangements for the project will leverage existing platforms and seek to strengthen capacities and systems for implementation of disease outbreak response and preparedness capacity. The Ministry of Health will be supported to handle its policy and strategy formulation roles and responsibilities, ensuring oversight and coordination.
31. The Coronavirus National Taskforce will coordinate the national response and provide strategic guidance for the implementation of the national program. The taskforce includes representatives of key ministries and government agencies, including the Ministry of Health/Rwanda Biomedical Center, Ministry of Local Government, Ministry of Finance and Economic Planning and others; as well as the main development partners active in the health sector, hence it is well placed to provide general oversight and advice. The taskforce is assisted by an Expert Advisory Team and a Command Post. The Expert Advisory Team provides
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
timely scientific advice for coordinated and informed-decision making process. The COVID-19 Command Post consists of a multi-disciplinary team from different departments/divisions of the Ministry of Health and the Rwanda Biomedical Centers responsible for the implementation and operationalization of the COVID- 19 Plan. The Command post team reports to the National Taskforce with respect to overall workplan implementation status, results framework update, procurement plan status, risk management plan, and escalates implementation bottlenecks for immediate decision and remedial actions. The Planning Cell of the Command Post will review the progress report of the project which would be approved by the Command Post Coordinator. The Command Post will approve the annual work plan for the project, and the associated budget and will monitor performance and budget execution.
32. The Rwanda Biomedical Center, the nation's central health implementation agency under the Ministry of Health will be responsible for overall project management through the Single Project Implementation Unit (SPIU) which has a long-standing sound track record of implementing several World Bank funded health investment operations. The RBC/SPIU will handle the following functions: (i) financial management, including flow of funds to different stakeholders; (ii) procurement of goods, medical and laboratory equipment, and supplies to ensure economies of scale and efficiencies; (iii) securing consultant services; and (iv) oversight of social and environmental safeguard provisions. The Bank team has done a review of the current capacity of the SPIU and found it satisfactory given the strong core procurement and financial management capacity. To handle the additional workload from the project, the SPIU will appoint the following: (i) Project Focal Point; and (iii) Environmental and Social Safeguards Specialist. A simple Project Implementation Manual will be prepared within one month of effectiveness, describing the main project activities and implementation modalities.
B. Results Monitoring and Evaluation Arrangements
33. The Project’s results framework includes both PDO and intermediate indicators. Indicators have been judiciously selected to assess the effectiveness and impact of project interventions. The SPIU/RBC will be responsible for: (i) compiling data; (ii) monitoring and tracking results and proposing cross corrections; and (iii) reporting results to the MoH and Prime Minister’s office and subsequently to the World Bank.
C. Sustainability
34. The sustainability of the project supported activities will hinge on continued strong government commitment; enhanced institutional capacity; and predictable financing. The commitment of the government of Rwanda to protecting the health and well-being of the population and putting in place strong public health measures has been strong and sustained and augurs well for sustainability. Key stakeholders at the national and decentralized levels continue to demonstrate strong ownership to contain outbreaks swiftly. Institutional capacity has been built over time with the proposed project further strengthening critical disease outbreak response and preparedness capacity, such as: (i) maintaining public awareness of the threat of COVID-19 and other rapidly spreading infectious diseases; (ii) supporting surveillance and prevention and control activities, particularly in high risk regions; (iii) bolstering country capacity to manage risk factors associated with the spread of COVID-19 and other infectious diseases at national and local levels. Further work is needed to ensure the financial sustainability of these activities, including greater levels of domestic financing.
V. PROJECT APPRAISAL SUMMARY
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
A. Technical, Economic and Financial Analysis
35. There is a strong economic rationale for investing in communicable disease control and for public provision of these services, as preventing and controlling disease outbreaks generates large and lasting economic benefits. Disease outbreaks can deter tourists and investors; cause severe economic shocks, including loss of jobs, drops in productivity and economic growth; and inflict lasting damage on stocks of both human and physical capital leading to drops in economic productivity and slowing long-term growth (UNDP, 2014). The ongoing COVID-19 global pandemic is a stark reminder of the astronomical human and economic costs associated with pandemics which can throw the global economy into a recession. The proposed investments in disease surveillance, laboratory systems, and outbreak preparedness and response are public goods because of inherent market failures, underscoring the important role of the public sector. As noted in the 2002 Global Public Goods for Health report by the WHO Commission on Macroeconomics and Health, priority should be placed on the provision of public goods, such as control and prevention of communicable diseases.
36. As seen during the 2014/2015 Ebola outbreak in West Africa and during other outbreaks, it is critical to act early and forcefully to avoid the high costs associated with disease outbreaks. The economic toll on the three most affected countries in West Africa was estimated at US$53 billion. In addition to the healthcare costs and productivity losses associated with Ebola and other epidemics, aversion behavior is a key risk factor which can drive away investors and tourists. The global cost of the ongoing coronavirus could be up to four times that of the 2003 SARS outbreak that sapped the world’s economy by US$40 billion, underscoring the interdependence of countries and illustrating how an outbreak in one country can rapidly spiral out of control into a global pandemic affecting nearly 180 countries across all continents.
37. The project focuses on best buy interventions and evidence-based approaches to disease outbreak preparedness and response and incorporates lessons learned from the national, regional and global level. Key lessons learned from the implementation of the East Africa Public Health Laboratory Networking Project (in which Rwanda participated during the first phase) are highlighted below (Box #1). The design has been guided by best practice in terms of the minimum package of interventions that countries should strive to attain for a comprehensive approach in line with the WHO guidelines. Strong and rapidly deployed Rapid Response Teams which are well trained can swiftly detect cases; well-equipped and staffed laboratories can ensure rapid and accurate confirmation of cases; and well trained and adequately protected clinical staff can triage and treat urgent cases. The proposed set of interventions will enable teams to respond quickly and reliably to COVID-19 and other public health threats, reducing the risk of transmission, and assisting health care providers to deal more efficiently with patients, ultimately reducing morbidity and mortality.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Box 1: Lessons Learned in Responding to Epidemics under the East Africa Public Health Laboratory Networking Project
• Early detection and accurate confirmation can contain epidemics quickly • Intervening early before outbreaks spiral out of control can save lives, reduce health care costs, and socio-economic losses • Early access to flexible funds can support countries to respond efficiently • Country-owned disease surveillance and outbreak response capacity with secure domestic financing is key to dealing with public health emergencies • Community involvement and clear communications can deal with socio-cultural issues and maintain trust in public health authorities • National, regional, continental and global institutions have important complementary and mutually reinforcing roles in coordinating and financing responses
B. Fiduciary
(i) Financial Management
38. The project will leverage the existing financial management and disbursement arrangements of the ongoing Stunting Prevention and Reduction Project (SPRP) (P164845). for its implementation. The project will rely on the existing accounting capacity at the RBC/SPIU. The implementing entity will deploy a dedicated project accountant or FM specialist to ensure effective discharge of FM activities under the project, including timely financial reporting to the World Bank. The SPIU will submit quarterly interim unaudited financial reports (IFRs) to the Bank within 45 days after the end of the quarter. The format of the IFRs was agreed with the World Bank during negotiations and the content will include key details of funds received and expenditure incurred under the project. External auditing of the project financial statements will be conducted by the Office of the Auditor General and the audit report will be submitted to the World Bank within six months after the financial year end.
39. The project includes several potential FM risks. Key potential risks include confirmation of delivery of the right quality and quantity of medical supplies and equipment; possibility of payments being made for substandard products or outputs or unintended beneficiaries. In addition, potential fund flow delays could impact delivery of key interventions under this emergency operation. There could also be challenges of project supervision as well as delayed IFRs and audit reports due to government-implemented measures to contain the spread of COVID-19. To address these risks, the project will rely on the country-level internal control framework established under the Rwanda Stunting Prevention and Reduction Project (P164845).
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
This includes confirmation of delivery of the right quantity and quality of medical supplies and equipment and certification of services rendered before payment. Payments will be made to beneficiaries’ bank accounts to mitigate the risk of loss or diversion of funds. The fund flow arrangements include flexibility of direct disbursement to suppliers and contractors to mitigate the risks associated with holding funds in the Designated Account. As much as possible, direct payments will be used to facilitate efficient implementation of the emergency operation and mitigate potential fiduciary risks. The Bank team will closely monitor the project and provide appropriate FM support in response to the evolving COVID-19 crisis. In particular, the team will enhance virtual engagement with the government project team to obtain relevant information regarding the effectiveness of project financial management arrangements. This includes desk review of IFRs, audit reports and similar reports, use of questionnaires for FM supervision, reliance on GPS technology to confirm project activities in diverse places and reliance on third party confirmation of existence of project outputs including any social accountability mechanisms. In cases where the government team would be unable to submit quarterly IFRs and annual audit reports, the Bank team will explore available flexibilities of extending submission dates or combining periods covered by IFRs and/or audit report in line with Bank Directive and Bank Procedure: IPF.
40. The disbursements will be based on Statements of Expenditures (SOEs), and the Bank, will review the underlying expenditures in the SOEs on a quarterly basis. The project will open one Designated Account denominated in US$ at the National Bank of Rwanda where payments for project activities will be made. A local currency project account will also be opened at the BNR for payments denominated in local currency.
41. The residual project FM risk is assessed as "Moderate”. The table below includes the main constituent elements of the risks and their respective mitigation measures. The implementation of the mitigation measures will be reviewed, and the FM risk will be reassessed as part of the continuous implementation support to the project.
42. Retroactive financing up to 60 percent of the total IDA credit will be allowed for eligible expenditures incurred by the government for the period between January 1, 2020 and the date of the signed Financing Agreement.11
11 All expenditures, for which retroactive financing is sought, will be submitted to the World Bank to verify their eligibility as per the project description and disbursement table, safeguards policies and procurement requirements as follows: (a) activities financed through retroactive financing are related to the development objective and are included in the project description; (b) payments are for items procured in accordance with the applicable Bank procurement rules; (c) total amount of retroactive financing is 40 percent or less of IDA credit; and (d) payments are made by the government during the period between January 1, 2017, and the date of the signed Financing Agreement.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
FM Risk Assessment and Mitigation Measures Type of Initial Brief Explanation Risk Mitigation Measures Condition of Residual Risk FM Risk incorporated in Project Design Effectiveness Risk Rating1 Rating (Y/N)? INHERENT RISK Country M The country’s political Establishment of MTEF as a basis No M Level environment is deemed for government budgeting, stable with ongoing judicial adoption of IPSAS, implementation and legislative reforms. of Smart IFMIS. Regular oversight Governance challenges through the OAG which is deemed including retention of independent and effective. Ongoing adequate accounting and Bank support to PFM and internal audit capacity across accountability. government, weak linkage between budgeted and actual performance. Likely macroeconomic challenges due to the impact of COVID- 19 Entity S MOH has previous Project implemented through a No M Level experience in dedicated SPIU at RBC with implementation of Bank necessary capacity deployed to projects through RBC SPIU. respond to increased workload COVID-19 restrictions likely Emergency operation responds to to impact delivery of project COVID-19 pandemic and has in- activities built arrangements to ensure implementation in difficult times
Project S There may be challenges MOH capacity to be enhanced to No M Level executing, monitoring and ensure adequate coordination. Hire coordinating decentralized of UN and NGO’s to support project activities implementation. Dedicated SPIU team in charge of day to day coordination while high- level National Steering Committee provides overall oversight. OVERALL M INHERENT S RISK
Type of Risk Initial FM Brief Explanation Risk Mitigation Measures Condition of Residual Risk Effectiveness Risk Rating1 Rating (Y/N)? CONTROL RISK Budgeting M Simplified budgeting Regular monitoring of budget No M arrangements for the execution through quarterly IFR emergency operation in line with country PFM systems Accounting S Existing accounting Additional dedicated accountant or No M
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Type of Risk Initial FM Brief Explanation Risk Mitigation Measures Condition of Residual Risk Effectiveness Risk Rating1 Rating (Y/N)? capacity at RBC SPIU FMS to be deployed for the project may be overstretched due to additional project workload
Internal controls, S Risk of delivery of Receipt and acceptance of No M management inadequate medical commodities to be confirmed oversight and risk commodities and before payment, payment of management supplies, funds may service providers to be supported not be paid to by proof of outputs and services intended service rendered. Also, payments to be providers, payments made to bank accounts designated may not be made for by the service providers. Internal intended purpose audit oversight at RBC to cover the project. Bank FM Supervision of project including virtual review of financial records and reports and FM questionnaire to SPIU staff Funds Flow S Potential funds flow Project to use direct payments as No M delays may affect much as possible to ensure faster delivery of the funds flow and reduce fiduciary emergency operation risks.
Financial Reporting S Delayed and Experienced RBC PIU staff with No M inaccurate IFR’s could capacity to submit accurate IFRs. affect project Regular follow up, training and hand fiduciary holding of project staff on financial performance reporting. Frequency and timelines for IFR submission could be reviewed in case of restrictions Auditing S Risk of delayed audit Alternative assurance mechanisms No M reports due to access including use of technology, desk restrictions review of reports, third party confirmation Frequency and timelines for submission of audit reports could be reviewed in case of restrictions OVERALL CONTROL M S RISK OVERALL PROJECT FM RISK Moderate (M)
H = High; S = Substantial; M = Moderate; L = Low.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
(ii) Procurement
43. Procurement under the project will be carried out in accordance with the World Bank’s Procurement Regulations for IPF Borrowers for Goods, Works, Non-Consulting and Consulting Services, dated July 1, 2016 (revised in November 2017 and August 2018). The project will be subject to the World Bank’s Anticorruption Guidelines, dated October 15, 2006, revised in January 2011, and as of July 1, 2016. The country will use the Systematic tracking of Exchanges in Procurement (STEP) to plan, record and track procurement transactions. 44. The major planned procurement includes: (i) medical/laboratory equipment and consumables, (ii) personal protective equipment, (iii) clinical and waste management equipment, (iv) minor rehabilitation and equipment of health facilities, (v) technical assistance, and (vi) human resources for response. Finalization of the streamlined project procurement strategy for development (PPSD) has been deferred to implementation. An initial procurement plan for the first three months has been agreed with the borrower and will be updated during implementation. 45. Country procurement approaches will utilize the flexibility provided by the Bank’s Procurement Framework for fast track emergency procurement by the countries. Key measures to fast track procurement include: (i) use of simple and fast procurement and selection methods fit for an emergency situation including direct contracting, as appropriate, (ii) streamlined competitive procedures with shorter bidding time, (iii) use of framework agreements including existing ones, (iv) procurement from UN Agencies enabled and expedited by Bank procedures and templates, (v) use of procurement agents, (vi) force account, as needed, and (vii) increased thresholds for Requests For Quotations s and national procurement, among others. As requested by the borrower, the Bank will provide procurement hands-on expanded implementation support to help expedite all stages of procurement – from help with supplier identification, to support for bidding/selection and/or negotiations to contract signing and monitoring of implementation. 46. Rwanda may be significantly constrained in purchasing critically needed supplies and materials due to significant disruption in the global supply chain, especially for Personal Protection Equipment. The supply problems that have initially impacted PPE are emerging for other medical products (e.g. reagents and possibly oxygen) and more complex equipment (e.g. ventilators) where manufacturing capacity is being fully allocated by rapid orders from developed countries. 47. Recognizing the significant disruptions in the usual supply chains for medical consumables and equipment for COVID-19 response, in addition to the above country procurement approach options available to countries, the Bank will provide, at borrowers’ request, Bank Facilitated Procurement (BFP) to proactively assist clients to access existing supply chains. Once the suppliers are identified, the Bank could proactively support borrowers with negotiating prices and other contract conditions. Borrowers will remain fully responsible for signing and entering into contracts and implementation, including assuring relevant logistics with suppliers such as arranging the necessary freight/shipment of the goods to their destination, receiving and inspecting the goods and paying the suppliers, with the direct payment by the Bank disbursement option available to them The BFP would constitute additional support to borrowers over and above usual Hands on Expanded Implementation Support which will remain available. If needed, the Bank could also provide hands-on support in contracting to outsource logistics. 48. BFP in accessing available supplies may include aggregating demand across participating countries, whenever possible, extensive market engagement to identify suppliers from the private sector and UN agencies. The Bank is coordinating closely with the WHO and other UN agencies (specifically WHO and UNICEF) that have established systems for procuring medical supplies and charge a fee which varies across
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
agencies and type of service and can be negotiated (around 5 percent on average.) In addition, the Bank may help borrowers access governments’ available stock. 49. All the procurement approach options mentioned above remain available depending on Rwanda’s preference in order to provide the most efficient and effective support to projects in the specific circumstances. These options were discussed and agreed on during negotiations. 50. Procurement implementation will be undertaken by Rwanda Biomedical Center, the implementing agency of the Ministry of Health.
51. Streamlined procedures for approval of emergency procurement to expedite decision making and approvals under the project has been agreed for implementation. Key measures to fast track procurement include the use of UN Agencies, direct contracting of firms, as appropriate, increased threshold for Request for Quotations (RfQ) to US$1 million and US$5 million for works. The Bank will provide procurement hands- on expanded implementation support to the Borrower to expedite procurement if requested by Government. Further, Bid Securing Declaration may be used instead of the bid security. Advance payments may be increased to 40 percent, while secured with the advance payment guarantee. The time for submission of bids/proposal can be shortened to 15 days in competitive national and international procedures, and to 3 days for the Request for Quotations, however if bidders request an extension it should be granted. Retroactive financing may be applied to the contracts procured in advance for the purpose of this project using procurement procedures consistent with Sections I, II and III of the Bank’s Procurement Regulations and consistent with the Financing Agreement.
52. Procurement Risks and Mitigation Measures. Procurement capacity and risk assessment has been carried out by the World Bank for the RBC to review the organizational structure for implementing the project. The agency has adequate experience in implementation of similar procurements. In addition, there are adequate number of experienced procurement staff at the SPIU/RBC. The key procurement risk is failed procurement by countries due to lack of enough global supply of essential medical consumables and equipment needed to address the health emergency as there is significant disruption in the supply chain, especially for PPE. All these factors could lead to difficulties and delays in meeting tight deadlines for this emergency project. The Procurement Risk Assessment and Management System (PRAMS) has been finalized. Based on the assessment and taking note of the factors noted above, the procurement risk rating is ‘Substantial’. The key risks and preliminary risk mitigation measures are indicated in Table 1 below. The residual risks after the implementation of the mitigation measures would remain “Substantial”.
Table 1: Procurement: Key Risks and Mitigation Measures Institutional Recommended Mitigation Key Risks Responsibility and Measures Timeframe -Lack of enough global supply of (a) World Bank to provide RBC and World critical equipment and supplies BFP to facilitate the Bank given significant disruptions in Borrower’s access to supply chains, especially for PPE available supplies, delineating clearly the roles of all parties to avoid perception of conflict of interest
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
-Heavy workload at SPIU could lead to delays in procurement (b) RBC to assign a dedicated procurement specialist who will be accountable and respond quickly, (b) introduce flexibilities to procurement regulation and (c) expand hands-on implementation support by WB APS
C. Legal Operational Policies
53. Given the personal nature of the information to be collected from patients and contact persons appropriate provisions need to be made to safeguard confidentiality. The project may involve the collection of personal data, and personally identifiable information and sensitive data in connection with the management of the COVID-19 outbreak under circumstances where sufficient measures to ensure the legitimate, appropriate and proportionate use and processing of that data may not feature in national law or data governance regulations, or be routinely collected and managed in health information systems. In order to guard against abuse of that data, the project will incorporate best international practices for dealing with such data in such circumstances. Such measures may include, by way of example, data minimization (collecting only data that is necessary for the purpose); data accuracy (correct or erase data that are not necessary or are inaccurate), use limitations (data are only used for legitimate and related purposes), data retention (retain data only for as long as they are necessary), informing data subjects of use and processing of data, and allowing data subjects the opportunity to correct information about them, etc. In practical terms, operations will ensure that these principles apply through assessments of existing or development of new data governance mechanisms and data standards for emergency and routine healthcare, data sharing protocols, rules or regulations, revision of relevant regulations, training, sharing of global experience, unique identifiers for health system clients, strengthening of health information systems, etc.
. . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No .
D. Environmental and Social Standards
54. Although this project is expected to have positive outcomes as it could improve COVID-19 surveillance, monitoring and containment, there are also potential environmental and social risks associated with the project financed activities. The main environmental and social risks and impacts of the project may result from Component -1 which will finance among other things medical supplies and equipment (e.g. thermo scanners; test kits; drugs; lab equipment and supplies, personal protective equipment) and Component-2 which will also fund medical and laboratory equipment and supplies as well as minor civil works (rehabilitate/adapt existing structures). Besides, the project will support the establishment of isolation centers (national and district
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
hospitals which would be responsible for triaging and treating COVID-19 cases) which can have potential environmental and social risks if not well managed.
55. The project could have substantial environmental, health and safety risks due to the dangerous nature of the pathogen (COVID-19) and reagents to be used in project-supported facilities. Infections due to inadequate adherence to occupational health and safety standards can lead to illness and death among healthcare workers. The laboratories which will be used for COVID-19 diagnostic testing can generate biological waste, chemical waste, and other hazardous biproducts. As the facilities to be supported by the project will process COVID-19 that can have the potential to cause serious illness or potentially lethal harm to the laboratory staff and to the community, effective administrative and containment controls should be put in place so minimize these risks. There are also occupational health and safety risks associated with the rehabilitation of medical facilities/minor civil works to be financed by the project. Wastes from the rehabilitation of medical centers could cause considerable environmental and social risks if not properly managed.
56. Environmentally and socially sound medical laboratory operations will require adequate provisions for minimization of occupational health and safety risks, proper management and disposal of hazardous waste (including sharps disposal), use of approved disinfectants, proper quarantine procedure for COVID-19, appropriate chemical and infectious substance handling and transportation procedures, and appropriate institutional/implementation arrangements for environmental and social risks. Moreover, the Environment and Social (ES) impacts of rehabilitation should be properly identified and managed. To proactively address potential environmental and social risks and impacts, the Rwanda Ministry of Health will prepare an Environmental and Social Management Framework (ESMF) using the ESMF template prepared by the World Bank OPCS department for COVID-19 projects. Medical facilities/isolation centers which will receive the project financed laboratory supplies and equipment will prepare site specific infection control and waste management plan.
The COVID ESMF will cover the procedures for the safe handling, storage, and processing of COVID-19 materials including the techniques for preventing, minimizing, and controlling environmental and social impacts during the operation of project supported laboratories. It will also include procedures to be followed in managing ES risks of health facility rehabilitation as well as the implementation arrangements to be established by the Rwanda Biomedical Center (RBC) for environmental and social risk management; training programs focused on COVID-19 laboratory biosafety, operation of isolation centers and screening posts, as well as compliance monitoring and reporting requirements. WHO COVID-19 biosafety guidelines will be reviewed while preparing the ESMF so that all relevant risks and mitigation measures will be covered. In addition to the ESMF, the client will prepare an Environmental and Social Commitment Plan (ESCP) and Stakeholders Engagement Plan (SEP) and allocate the resources necessary for implementation of the ESCP and the SEP in the proposed project. The Bank will support the counterpart team to review the final specification and training materials.
57. The social risk classification is ”Substantial”. Rwanda has become the first country in sub-Saharan Africa to take the necessary measure to order a total shutdown because of the coronavirus. As of March 23rd, 2020, Rwanda has confirmed about 20 cases of COVID-19. All unnecessary movements outside the home have been banned for an initial two weeks except for essential services such as health care and shopping for groceries. Both public and private workers have also been ordered to work from home to help prevent the spread of COVID-19.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
58. As a result of lack of resources to prepare and protect against the coronavirus, the poor face a higher risk of contracting and subsequently spreading the virus. Informal sector workers, like street vendors, construction workers, and those in low-income jobs or in jobs that cannot be performed remotely, are most vulnerable, as these people often have no savings to weather the storm, and even stocking up on food can represent an impossible financial hurdle. The harm inflicted on especially urban poor and many women heads of households, is likely to be devastating. In informal urban settlements, families occupy cramped informal dwellings, and just barely survive by peddling goods in the city, work that is now banished to stop contagion. Men tend to work as day laborers, pulling trolleys of goods to the bazaar, and are now out of work, as trade is curtailed.
59. Amidst all these turbulent times, the government will engage all stakeholders in an efficient and effective way. The client has prepared a Stakeholders Engagement Plan (SEP) that outlines the stakeholder’s engagement strategies for this project. To ensure effective communication WHO has developed the Risk Communication and Community Engagement (RCCE) readiness and response to the 2019 novel coronavirus to guide governments. The document provides checklists developed by WHO for risk communication and community engagement (RCCE) readiness provide actionable guidance for countries to implement effective RCCE strategies that will help protect the public’s health during the early response to COVID-19. To support these efforts, the project has included a component on RCCE, encompassing behavioral and sociocultural risk factor assessments, production of communication materials, media and community engagement, and documentation in line with WHO “Pillar 2: Risk communication and community engagement.” The approaches taken will thereby ensure that information is meaningful, timely, and accessible to all affected stakeholders, including use of materials in the local language, addressing cultural sensitivities, as well as challenges deriving from illiteracy or disabilities.
60. The overall project SEP outlines a structured approach to engagement with stakeholders that is based upon meaningful consultation and disclosure of appropriate information, considering the specific challenges associated with COVID-19. In cases of the most vulnerable – the elderly and those with compromised immune systems due to pre-existing conditions, stakeholder engagement will minimize close contact and follow the recommended hygiene procedures as outlined in the CDC Interim Infection Prevention and Control Recommendations for patients with confirmed COVID-19 or persons under investigation for COVID-19 in healthcare settings. People affected by project activities, including construction workers at health facilities, will be provided with accessible and inclusive means to raise concerns and grievances. Beyond this immediate concern, project implementation also needs to ensure appropriate stakeholder engagement to: (i) avoid conflicts resulting from false rumors; (ii) facilitate access to vulnerable groups; and/or (iii) address issues resulting from people being kept in quarantine.
VI. GRIEVANCE REDRESS SERVICES
61. Communities and individuals who believe that they are adversely affected by a World Bank supported project may submit complaints to existing project-level grievance redress mechanisms or the Bank’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 Bank’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of Bank 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
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
has been given an opportunity to respond. For information on how to submit complaints to the 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.
VII. KEY RISKS
62. The overall project risk rating is Substantial. There are several substantial risks to the project, including: (i) adverse effects on the macroeconomic and fiscal situation of the government of Rwanda stemming from COVID-19; (ii) health sector institutional capacity, which can be easily overwhelmed if there is a surge in the number of new cases; and (iii) fiduciary concerns, including procurement related problems, stemming from potential difficulties in procuring critical equipment given the disruptions in global supply chains. The table below identifies the main risks, proposes mitigation measures, and notes the residual risks. Based on the assessment of these important risks, which stem in large part from the heavily constrained global supply chain, the overall risk of the proposed project is therefore rated Substantial.
Main Risks Mitigation Measures Risk Rating
Macroeconomic: Reduction in fiscal capacity of -The health sector project would partly mitigate Substantial governments due to global economic this risk by supporting critical public health disruption and slowdown, and potential programs, in addition to the COVID-19 response decline in fiscal revenues, given expected and mitigation efforts. downturn in aviation, tourism and conferences. The resulting fiscal -A budgetary support operation under constraints could negatively impact discussion will partly mitigate the economic public health service delivery with fallout from the coronavirus outbreak in respect to COVID-19 prevention, Rwanda. mitigation, and treatment, in addition to other essential health services.
Health sector institutional capacity for -The government has already put in place a Substantial implementation and sustainability: national lock down policy for the next two The severity and unpredictability of the weeks and has adopted stringent, mandatory coronavirus global pandemic poses social distancing policies and will need to potential high risks to Rwanda, both in monitor and enforce these measures. terms of its ability to respond swiftly to a rapid rise in the number of reported -The project will support interventions to cases as well as to sustain other critical conduct risk assessments and conduct health services, particularly if there is epidemiological surveillance, to facilitate rapid transmission to high-density rural areas. responses.
Lack of predictable financing for COVID- -The project will fund operational costs 19 and other disease outbreaks (including recruitment of additional personnel), while the HD DPO will include policy measures to strengthen the availability of human
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Project implementing agencies have resources for health and address chronic variable capacity to mitigate the impact understaffing in the health sector. of COVID-19 -Further work is needed to mobilize domestic resources for disease outbreak response and preparedness and to mainstream these interventions in the government’s budget.
-Government will implement the COVID-19 response through existing structures at the RBC/SPIU which have experience and a sound track record in implementing similar public health programs.
Fiduciary: -World Bank to provide BFP to facilitate the Substantial Lack of enough global supply of critical Borrower’s access to available supplies, equipment and supplies given significant delineating clearly the roles of all parties to disruptions in supply chains avoid perception of conflict of interest.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
6.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
VIII. RESULTS FRAMEWORK AND MONITORING
Results Framework COUNTRY: Rwanda Rwanda COVID-19 Emergency Response Project
Project Development Objective(s) The objective of the Project is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in the Republic of Rwanda.
Project Development Objective Indicators
RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target
Project Development Objective Indicators
Proportion of suspected COVID-19 cases reported and 80.00 100.00 investigated based on national guidelines (Percentage)
Number of designated laboratories with COVID-19 diagnostic 1.00 4.00 capacity (equipment, test kits, reagents) (Number)
Proportion of designated healthcare facilities with isolation 20.00 100.00 capacity (Percentage)
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
PDO Table SPACE
Intermediate Results Indicators by Components
RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target
Component 2: Public Health Measures and Clinical Care Capacity Proportion of targeted healthcare facilities with clinical capacity 20.00 100.00 for COVID-19 patients (Percentage) Number of health staff trained in infection prevention and control (Number) 20.00 145.00 Component 1. Case Detection, Confirmation and Contact Tracing Number of laboratory staff trained to conduct COVID-19 diagnosis (Number) 0.00 50.00
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 Suspected COVID-19 cases: a person with at least one COVID-19 symptoms COVID-19 Proportion of suspected COVID-19 cases (fever, couth, shortness of Quarterly investigation COVID-19 investigation RBC reported and investigated based on breath sore throat), or a report national guidelines close contact within 14
days of onset of symptoms with a person under investigation for COVID-19,
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
or a person with a recent travel history to a COVID- 19 affected country.
The indicator counts percentage of total suspected COVID-19 cases reported and tested which are investigated based on national guidelines Numerator: Number of National laboratories with Reference equipment, test kits and Laboratory reagents capable of doing Number of designated laboratories with (Laboratory COVID-19 testing Quarterly Project monitoring RBC COVID-19 diagnostic capacity (equipment, network test kits, reagents) supervision/as Denominator: Total sessment number of laboratories report) designated to provide
COVID-19 testing Numerator: Number of Health facility designated health facilities supervision / Proportion of designated healthcare with isolation capacity Quarterly Project monitoring RBC assessment facilities with isolation capacity report Denominator: Number of
designated health facilities ME PDO Table SPACE
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Total number of targeted healthcare facilities with capacity to Health facility Proportion of targeted healthcare treat COVID-19 patients supervision / Quarterly Project monitoring RBC facilities with clinical capacity for COVID- assessment
19 patients Denominator: Total report number of targeted health care facilities for COVID-19 patients Total health staff (medical doctors, nurses and IPC training Number of health staff trained in infection Quarterly Project monitoring RBC laboratory technicians) report prevention and control trained on IPC per MOH- approved protocols. Total number of staff at targeted laboratories (e.g. laboratories at district hospitals, provincial hospitals, referral hospitals, Laboratory Number of laboratory staff trained to Quarterly Project monitoring RBC national hospitals, training report conduct COVID-19 diagnosis specialized hospitals and the National Reference Laboratory) who benefited from training
ME IO Table SPACE
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
.
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
ANNEX 1: Project Costs
COUNTRY: Rwanda Rwanda COVID-19 Emergency Response Project
COSTS AND FINANCING OF THE COUNTRY PROJECT
Project IBRD or IDA Trust Counterpart Program Components Cost Financing Funds Funding
Component 1: Case Detection, Confirmation and Contact 5.9 Tracing -Disease Surveillance, RRTs and case investigation 2.2 -Laboratory Capacity and Specimen Transport 2.8 -Points of Entry 0.9
Component 2: Public Health Measures and Clinical Care 8.0 Capacity -Risk Communication and Community Engagement 0.4 -Case management/specialized units/lab capacity 5.8 -Infection Prevention and Control 1.8 .35 Component 3: Program/Project Management and M&E
-Country level coordination, planning, and monitoring .20 -Project Management .15
Component 4: CERC 0
Total Costs 14.25
Total Costs
Total Costs 14.25
Front End Fees
Total Financing Required
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
ANNEX 2: Rwanda JEE Scores
Metric (JEE Assessment Tool indicators) Score (1-5) P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government 3 instruments in place are sufficient for implementation of IHR. P.1.2 The state can demonstrate that it has adjusted and aligned its domestic legislation, policies, 3 and administrative arrangements to enable compliance with the IHR (2005). P.2.1 A functional mechanism is established for the coordination and integration of relevant 3 sectors in the implementation of IHR P.3.1 Antimicrobial resistance (AMR) detection 1 P.3.2 Surveillance of infections caused by AMR pathogens 1 P.3.3 Healthcare associated infection (HCAI) prevention control programs 1 P.3.4 Antimicrobial stewardship activities 1 P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens 3 P.4.2 Veterinary or Animal Health Workforce 3 P.4.3 Mechanisms for responding to infectious zoonoses and potential zoonoses are established 3 and functional P.5.1 Mechanisms are established and functioning for detecting and responding to foodborne 3 disease and food contamination. P.6.1 Whole-of-government biosafety and biosecurity system is in place for human, animal, and 3 agriculture facilities P.6.2 Biosafety and biosecurity training practices 3 P.7.1 Vaccine coverage (measles) as part of national program 5 P.7.2 National vaccine access and delivery 5 D.1.1 Laboratory testing for detection of priority diseases 4 D.1.2 Specimen referral and transport system 3 D.1.3 Effective modern point of care and laboratory based diagnostics 3 D.1.4 Laboratory Quality System 4 D.2.1 Indicator and event based surveillance systems 4 D.2.2 Interoperable, interconnected, electronic real-time reporting system 2 D.2.3 Integration and analysis of surveillance data 4 D.2.4 Syndromic surveillance systems 4 D.3.1 System for efficient reporting to WHO, FAO and OIE 3 D.3.2 Reporting network and protocols in country 2 D.4.1 Human resources are available to implement IHR core capacity requirements 2 D.4.2 Applied epidemiology training program in place such as FETP 3 D.4.3 Workforce strategy 3 R.1.1 Multi-hazard national public health emergency preparedness and response plan is 2 developed and implemented
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The World Bank Rwanda COVID-19 Emergency Response Project (P173855)
R.1.2 Priority public health risks and resources are mapped and utilized 2 R.2.1 Capacity to Activate Emergency Operations 2 R.2.2 Emergency Operations Centre Operating Procedures and Plan 3 R.2.3 Emergency Operations Program 4 R.2.4 Case management procedures are implemented for IHR relevant hazards 2 R.3.1 Public Health and Security Authorities, (e.g. Law Enforcement, Border Control, Customs) are 5 linked during a suspect or confirmed biological event R.4.1 System is in place for sending and receiving medical countermeasures during a public health 2 emergency R.4.2 System is in place for sending and receiving health personnel during a public health 1 emergency R.5.1 Risk Communication Systems (plans, mechanisms, etc.) 1 R.5.2 Internal and Partner Communication and Coordination 5 R.5.3 Public Communication 5 R.5.4 Communication Engagement with Affected Communities 4 R.5.5 Dynamic Listening and Rumour Management 4 PoE.1 Routine capacities are established at PoE 2 PoE.2 Effective Public Health Response at Points of Entry 1 CE.1 Mechanisms are established and functioning for detecting and responding to chemical 3 events or emergencies CE.2 Enabling environment is in place for management of chemical event 3 RE.1 Mechanisms are established and functioning for detecting and responding to radiological 3 and nuclear emergencies RE.2 Enabling environment is in place for management of Radiation Emergencies 3 Average score 2.9 Overall Performance (%) 58.0
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