Attachment_12-_CHAIN_and_S-TIME_PADs.pdf

Community Health and Improved Nutrition Project Appraisal Document Page 1

Community Health and Improved Nutrition (CHAIN)

Project Appraisal Document (PAD)

Public Version of the PAD as Amended through Amendment 4, October 25, 2017

Community Health and Improved Nutrition Project Appraisal Document Page 2

TABLE OF CONTENTS

I. INTRODUCTION AND OVERVIEW 3

II. PROJECT DESCRIPTION 4

Results Framework 5

CHAIN Collaboration Framework: 8

III. DISCUSSION OF RESULTS FRAMEWORK AND CORRESPONDING INTERVENTIONS 9

Sub-Purpose 1: Increased awareness of, demand for, and access to high-impact health practices 9

Output 1.1: Increased access to key health services among target populations 9

Output 1.2: Increased access to water and sanitation services among target populations 9

Output 1.3: Improved availability of and access to priority health products 10

Output 1.4: Increased health-seeking behaviors and demand for priority health products and services 10

Sub-Purpose 2: Improved protection of vulnerable populations against adverse circumstances 11

Output 2.1: Increased capacity of families and communities to provide better care for vulnerable individuals 11

Output 2.2: Improved household and community care and support practices for vulnerable populations, especially children 11

Output 2.3: Increased access to education and social services for vulnerable populations 12

Sub-Purpose 3: Increased nutrition knowledge and adoption of appropriate nutrition and hygiene practices 12

Output 3.1: Increased food security for vulnerable populations 13

Output 3.2: Improved WASH actions to reduce diarrheal disease 13

Output 3.3: Improved nutrition behaviors 14

Sub-Purpose 4: Improved performance and engagement by CSOs and GOR entities 15

IV. PROJECT IMPLEMENTATION MECHANISMS 16

Overview of Project Activities 16

Opportunities for Policy Engagement 17

ANNEX A: M&E Plan 20

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I. INTRODUCTION AND OVERVIEW

This project appraisal document (PAD) informs the design of activities supported by USAID/Rwanda to increase the utilization of quality health services and products by target populations and communities. These mechanisms and activities constitute the Community Health and Improved Nutrition (CHAIN) Project, a seven-year (FY2014-FY2020), $182 million project.

USAID/Rwanda’s Country Development Cooperation Strategy (CDCS)1 aims to accelerate Rwanda’s progress to middle income status and better quality of life through sustained growth and reduction of poverty by realizing four development objectives (DO). DO3—Health and nutritional status of Rwandans improved—acknowledges the links between the health of Rwandans and the country’s economic growth as well as the role of human development in breaking intergenerational cycles of poverty. USAID’s contribution to DO3 is further broken down into two intermediate results (IR): IR 3.1, focused on strengthening the capacity of the health sector to deliver high quality services, and IR 3.2, focused on increasing utilization of quality health services/products by target populations and communities. CHAIN will address IR 3.2. The CDCS prioritizes gender-sensitive approaches and institutional capacity building as key foundations of both achieving and sustaining all of USAID’s objectives in Rwanda.

Adopting an integrated approach to health and human development, CHAIN will include health promotion, water, sanitation and hygiene (WASH); social marketing and HIV prevention interventions; strengthening of social services to vulnerable populations, especially women during pregnancy and lactation, children, and people living with HIV (PLHIV); and interventions addressing the nutrition challenges confronting Rwanda at this time. In addition to strengthening the capacity of individuals, households, and community structures to improve their health, nutritional, and socioeconomic status, the project will support activities strengthening the Government of Rwanda (GOR) capacity and the capacity of civil society organizations (CSOs).

Acknowledging that nutrition and comprehensive human development depends on several factors that are inter-sectoral in nature, the CHAIN project will link to and take advantage of mechanisms and activities supported across the Mission, to create efficiencies and optimize the achievement of Mission goals and objectives.

The CHAIN project will align with and contribute to the following USAID priorities:

● Global Health Initiative

● President’s Emergency Plan for AIDS Relief (PEPFAR) Blueprint: Creating an AIDS-Free

Generation

● United States Government (USG) Action Plan on Children in Adversity

● Ending Preventable Child and Maternal Deaths (EPCMD)

● USAID Forward

● The USG Feed the Future Multi-Year Strategy for Rwanda2

● USAID Water and Development Strategy

● USAID Gender Equality and Female Empowerment Policy,3 operationalized for CHAIN via the CHAIN Project Gender Analysis4

1 USAID/Rwanda. Country Development Cooperation Strategy: 2014-2018. September 2014.

https://www.usaid.gov/sites/default/files/documents/1860/Rwanda-CDCS-Approved-Public-Version.pdf 2 USG. Feed the Future Rwanda FY 2011–2015 Multi-Year Strategy. 2011. feedthefuture.gov/resource/rwanda-feed-future-multi-year-strategy 3 USAID. Gender Equality and Female Empowerment Policy. March 2012.

https://www.usaid.gov/sites/default/files/documents/1865/GenderEqualityPolicy_0.pdf 4 USAID/Rwanda. Gender Analysis for USAID/Rwanda Community Health and Improved Nutrition (CHAIN) Project. July 2014.

https://www.usaid.gov/sites/default/files/documents/1860/GA%20-%20CHAIN%20project%20-%20FINAL%20Aug%2011%202014%20-https://www.usaid.gov/sites/default/files/documents/1860/Rwanda-CDCS-Approved-Public-Version.pdf http://feedthefuture.gov/resource/rwanda-feed-future-multi-year-strategy http://feedthefuture.gov/resource/rwanda-feed-future-multi-year-strategy https://www.usaid.gov/sites/default/files/documents/1865/GenderEqualityPolicy_0.pdf https://www.usaid.gov/sites/default/files/documents/1860/GA%20-%20CHAIN%20project%20-%20FINAL%20Aug%2011%202014%20-%20Public%20Version.pdf

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CHAIN will also collaborate with several related USAID/Rwanda projects and activities:

● Strengthening Capacity of Health Sector to Deliver Quality Health Services in Rwanda (SCHS) Project

● System Transformation for Income, Market, and Employment (S-TIME) Project

● Youth Sustainable Partnerships for Education and Economic Development Project

● Huguka Dukore Activity

Key partners for CHAIN include:

Key Partner Country Institutions

Key Partner Donors and Multilateral Organizations

Key Partner NGOs Not Currently Receiving USAID Funds

Ministry of Health and Rwanda Biomedical Center

World Health Organization Clinton Health Access Initiative

(CHAI)

Ministry of Local Government United Nations Children’s Fund Project Healthy Children (PHC)

Ministry of Gender and Family Promotion

Global Fund

Ministry of Agriculture United Kingdom, European Union, Belgium, Denmark, Luxembourg, Germany, the Netherlands, and Switzerland

Ministry of Infrastructure Japan International Cooperation Agency (JICA)

University of Rwanda College of Medicine and Health Sciences, School of Public Health

Other USG agencies working in Rwanda: Centers for Disease Control and Prevention, Department of Defense, and Department of Agriculture

District governments

II. PROJECT DESCRIPTION

Problem statement Inequality in health and nutrition outcomes, often driven by inadequate utilization of quality health services/products and behaviors among vulnerable populations, limits human development and the ability of Rwandans to break intergenerational cycles of poverty. Moreover, economic, health, and nutrition inequality are mutually reinforcing and need to be addressed concurrently if the development challenge they represent is to be resolved. In order to achieve the Mission Goal of accelerating Rwanda’s progress to middle income status and better quality of life through sustained growth and reduction of poverty, we must address health and nutrition inequality in Rwandan society.

%20Public%20Version.pdf https://www.usaid.gov/sites/default/files/documents/1860/GA%20-%20CHAIN%20project%20-%20FINAL%20Aug%2011%202014%20-%20Public%20Version.pdf

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Development hypothesis If 1) priority populations improve their socioeconomic status and food security and adopt positive parenting, feeding, and hygiene practices; 2) awareness of, access to, and demand for high-impact health practices among these populations is increased; and 3) the performance of and engagement by civil society organizations in the health sector is improved, then the utilization of quality health services and products by target populations and communities will increase and they will be able to improve and sustain the health of themselves and the vulnerable individuals in their care.

End-of-project outcome By the end of the CHAIN project, households and individuals will have improved access to health, nutrition, and WASH products and services and will have adopted healthy behaviors and improved health seeking behaviors, resulting in an improved health and nutrition status, including reduced stunting, for target populations. These results will be especially apparent among the most vulnerable individuals including pregnant and lactating women, young children, orphans and vulnerable children (OVC), and key populations (female sex workers and men who have sex with men), contributing to reduced health inequalities. It is expected that local CSOs will have improved links with local government programs providing health and social services, and there will also be increased capacity and engagement of the private sector in delivering specific health and nutritional products.

Mechanisms that link and coordinate Rwandan CSO efforts with those of GOR health system and social services, such as community health workers (CHWs), one-stop centers for gender-based violence (GBV), Vision Umurenge Program (VUP), and community health insurance, will be forged and strengthened.

These outcomes will be measured through four project purpose-level indicators:

● Number of family planning users who started using modern contraceptives following USG communications

● Prevalence of children 6-23 months receiving a minimum acceptable diet in USAID-supported districts

● Percent of households in target areas practicing correct use of recommended household water treatment technologies

Percentage of households with soap and water at a handwashing station commonly used by family members

Geographic focus and coverage The geographic focus of each activity under the CHAIN project will be determined based on a number of factors including geographic analyses of the development problem(s) to be addressed, coverage of relevant interventions by other donors and partners, and the geographic focus of complementary USAID-funded activities under CHAIN and other relevant projects.

Results Framework The USAID/Rwanda Health Office contributes to the following portion of the mission’s results framework:

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The results framework for CHAIN builds on IR 3.2 and expands its sub IRs (named sub-purposes in this PAD) into the outputs and activities described in the following results framework and the text.

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CHAIN Results Framework:

It is hypothesized that the different components of the CHAIN results framework fit together in the form of a collaboration framework, with the different results framework outputs and sub-purposes contributing to and supporting one another’s achievement as depicted below.

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CHAIN Collaboration Framework:

It is further hypothesized that the interactions between the different components of the results framework as depicted in the collaboration framewerk will lead to better outcomes through at least one of the following mechanisms:

● Hypothesis 1: With greater collaboration, each of the CHAIN mechanisms will not only be able to meet their objectives but also exceed and/or achieve other unexpected positive outcomes

● Hypothesis 2: With greater collaboration, overall costs are reduced as a result of greater efficiency gained by better planning, sharing and coordination of resources

● Hypothesis 3: With greater collaboration, there is stronger alignment and coherence in the

Community Health and Improved Nutrition Project Appraisal Document Page 9 strategic design, planning and implementation of community-based health and development work carried out by USAID partners (and which also helps further the GoR's development agenda)

These will be tested throughout the implementation of the Project according to a project-specific learning agenda that will be developed following the midterm evaluation of the project.

III. DISCUSSION OF RESULTS FRAMEWORK AND CORRESPONDING

INTERVENTIONS

Sub-Purpose 1: Increased awareness of, demand for, and access to high-impact health practices Development Logic: Well-recognized bottlenecks to achieving coverage of life-saving interventions in community settings are lack of knowledge, poor utilization and poor quality of services. The underlying premise of Sub-purpose 1 is that households and communities have tremendous incentive to improve their health; however, they often lack awareness of and capacity to demand and access quality health services and products.5 Empowered to become active actors in their health care, families are expected to adopt more effective health practices and behaviors, and seek/demand proper care from CHW and health facilities.

Output 1.1: Increased access to key health services among target populations The Modes of Transmission study carried out in Rwanda by the Rwanda Biomedical Center identified the top four groups that will contribute to new HIV infection in the coming years:

1. Stable heterosexual relationships (65%).

2. Female sex worker (FSW) networks composed of FSWs, their clients, and their non-paying partners (20%).

3. Those participating in casual heterosexual sex (10%), interpreted as youth aged 15-24, as they compose the majority of sexually active individuals out of union.

4. Men who have sex with men (MSM) (5%).

These priority groups are identified in the National Strategic Plan (NSP) for HIV as key populations.6 Among these priority groups, female youth have a significantly higher HIV prevalence rate than males of the same age, especially among 20-24 year olds, with an HIV prevalence rate of 2.4% among females and 0.5% among males.

Community-based organizations (CBOs) will link target populations and those who may otherwise be hard to reach (e.g., PLHIV and mobile populations) with clinical services. The partners will also provide key and vulnerable populations with HIV and sexually-transmitted infections (STI) prevention packages and reproductive health services. The project will continue to build the capacity of local organizations to do this work.

A key activity under this output will be to provide key populations—female sex workers, their clients, and MSM—with integrated prevention packages. Innovative ways of reaching key populations and target populations, such as Safe-T-Stop centers, have been developed and will be continued.

Output 1.2: Increased access to water and sanitation services among target populations Water, sanitation, and hygiene are highlighted in Rwanda’s Economic Development and Poverty Reduction Strategy 2 (EDPRS 2), and the Rwandan government has committed to attaining 100% coverage of water and sanitation by 2018.7 To support this goal, CHAIN will work with district governments in developing district water and sanitation plans explicitly considering gender and

5 Ensor, Tim and Stephanie Cooper. “Overcoming barriers to health service access: influencing the demand side.” Health Policy and Planning. (2004) 19 (2): 69-79 http://heapol.oxfordjournals.org/content/19/2/69.full.pdf+html 6 National HIV and AIDS Strategic Plan 2013-2018 7 Republic of Rwanda (n.d.). EDPRS 2 2013-2018.

http://heapol.oxfordjournals.org/content/19/2/69.full.pdf+html

Community Health and Improved Nutrition Project Appraisal Document Page 10 equity. The project will also support expanding access to drinking water supply using public-private partnerships, while building technical and managerial capacity within the district government and private operators.

In consultation with other sector stakeholders, CHAIN will map and assess existing sanitation supply chains, products, and services, and seek to catalyze the sanitation market. CHAIN will work with both existing and potential new supply chain actors and entrepreneurs, potentially through Global Development Alliance (GDA) partnerships.

These investments will be supported by policy and regulatory level interventions addressing issues related to sustainability, cost, financing, and quality. In the private sector, CHAIN will encourage entrepreneurship, especially among women, for provision of water and sanitation products and services. These activities will be complemented by Output 3.2, Improved WASH actions to reduce diarrheal disease.

Output 1.3: Improved availability of and access to priority health products Many health products, including contraceptives, are provided for free by public health facilities, and much of the Rwandan population is able to access priority health products through the public sector.

Social marketing provides another source for health products, at a price point which is lower than private sector prices. This is key to increasing access, particularly among targeted populations such as FSWs and MSM, as social marketing activities can be targeted towards these distinct target groups and provided in locations frequented by these groups, rather than in public health facilities that are often not regularly utilized by these groups.

Under CHAIN, USAID will continue to support the social marketing of priority health products including condoms, contraceptives, and safe water products; while potentially expanding to new products including nutritional supplements. This support will transition out beginning in FY 2016 and continue into FY 2018 to conclude with a sole focus on condom distribution and social marketing.

In addition, although access to improved sanitation is fairly high in rural Rwanda, there are some product design improvements that would make household sanitation both more aspirational and also more hygienic. Social and/or commercial marketing of low-cost latrine products and services may be explored to reduce exposure to feces from poorly designed and/or maintained latrines.

Output 1.4: Increased health-seeking behaviors and demand for priority health products and services Health communication activities that both increase awareness of and demand for key health products and services, and enhance behavior change and promote health seeking behaviors on issues related to HIV/AIDS, malaria, reproductive health, family planning, maternal and child health, nutrition, hygiene, and safe water use at the community and household level will be developed and implemented under this output. There will be a focus on integrating messages across partners and between health products and services when appropriate.

A key issue for adolescents, according to the Rwandan Integrated Children’s Rights Strategy, is reproductive health; young people’s vulnerability in this area has also been highlighted in the Health Sector Strategic Plan III (HSSP III) and the Joint Assessment of National Strategies (JANS).8 This output will develop activities for this target group using evidence-based approaches and messaging.

A focus on real-time evaluative methods for these BCC interventions will also be incorporated.

8 Rwanda, MTR-JANS HSSP II, Final Report, 2011

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Sub-Purpose 2: Improved protection of vulnerable populations against adverse circumstances Development Logic: Effective responses to the needs of vulnerable populations increase people's resilience to respond to the impact of HIV and other health or economic threats. Under CHAIN, responses will focus on knowledge-based skills development, while resilience will include household level capacity (i.e., knowledge, opportunities, and resources). Vulnerable groups under this sub-purpose are defined as PLHIV; OVC; members of the household caring for OVC and/or PLHIV; very poor households, especially female- and widow-headed households; and out-of-school youth, especially girls; and adolescent girls and young women under DREAMS. This vision is closely aligned with the GOR’s EDPRS 2, the National Social Protection Strategy, the Rwanda National HIV and AIDS Strategic Plan, and the Rwanda National Policy on Orphans and Vulnerable Children.

Output 2.1: Increased capacity of families and communities to provide better care for vulnerable individuals USAID/Rwanda hypothesizes that if families have an improved economic position, they will be in a position to access health and social services for their family members, particularly children. To this end, the project will address the vulnerabilities of HIV/AIDS affected households and communities by stabilizing household assets, improving nutrition and food security, generating income, and fostering market linkages. Economic strengthening activities such as savings and lending groups, cooperatives, and market-related agricultural improvements will be continued. These type of activities have been shown to have a positive effect on a family’s economic position, and in turn, on the health of children in these families.9

Within this output, cooperatives and other existing structures will be assisted to engage with CHWs at suitable junctures and to build financial planning skills into their assistance to members, focusing on local health insurance, identifying and addressing health needs early, and innovative mechanisms for decreasing costs associated with health. Women and youth-friendly economic strengthening activities will be combined with skills training, life skills, and sexual and reproductive health information.

Output 2.2: Improved household and community care and support practices for vulnerable populations, especially children In Rwanda, care-seeking behavior for children is low. Just 50.2% of children with symptoms of acute respiratory infections, 42.7% of those with fever, and 37% of those with diarrhea are taken to a health facility/provider (DHS 2010). Moreover, it is estimated in the Rwanda HIV and AIDS National Strategic Plan that up to 50% of eligible children are not accessing antiretroviral therapy (ART).

Many programs focused on OVC are uniquely poised to expand and extend health care knowledge, practices, and services to reach women, infants, and children who are less likely to present in clinics, resulting in greater protection from adverse circumstances (Guidance for Orphans and Vulnerable Children Programming, PEPFAR 201210). In addition, there is opportunity for tracing patients who are lost to follow up for key health services.

Activities associated with this output will encourage better care practices in families for OVC and other vulnerable family members through home visits, training sessions, after-school programs, positive deviance approaches, and behavior change communication strategies. These activities will support communities to address barriers that limit healthy outcomes for vulnerable populations (e.g., attitudes around pregnancy and eating, early childhood development (ECD), WASH, harmful gender norms, alcohol use, etc.). Approaches to specifically address the special needs of infants and young children and their guardians, as well as interventions to address barriers to healthy practices faced by women and girls, will be developed. Male engagement in health behaviors, especially family planning, prevention of mother-to-child transmission (PMTCT), antenatal care (ANC), infant and

9 Associated Consultants for Consultancy Services, Household Economic Resilience Assessment Report for the USAID/Higa Ubeho Program, September 2003.

10 PEPFAR Guidance for Orphans and Vulnerable Children, 2012. http://www.pepfar.gov/documents/organization/195702.pdf

Community Health and Improved Nutrition Project Appraisal Document Page 12 childcare, and child health and nutrition will be encouraged.

In addition, this output will benefit CSOs and the GOR. Support to the work of the GOR’s emergent community social workers and animators will be explored and developed. The technical capacity of CSOs to undertake effective home visits with appropriate frequency, quality, duration, and input will be strengthened.

Output 2.3: Increased access to education and social services for vulnerable populations This output considers the capacity of local government institutions, local community groups, and local civil society organizations to deliver their mandated services to OVC and vulnerable people, according to the Social Protection Strategy of the GOR.11 It will strengthen local community-based structures and organizations to address the needs of vulnerable populations sustainably, in part by linking them to GOR programs but also by building institutional and technical capacity so that local organizations can access and adopt international best practices. Best practices to be adopted will include innovative ways of ensuring that OVC attend and progress through school.

The project will also work with local leaders, including religious leaders and opinion leaders, to analyze and address gender issues. Approaches to sustainably increase the capacity of local government, community, and CSOs to support and respond to the psychosocial needs of vulnerable households, survivors of GBV, and children will be incorporated.

This output will complement the Mission’s work under DO 4, Increased Opportunities for Rwandan Children and Youth to Succeed in Schooling and the Modern Workplace by1) improving the quality of basic education to which vulnerable children will be referred and 2) strengthening opportunities for youth transitioning into the workforce. Quality educational institutions need to be child-friendly and sensitive to needs of orphans and vulnerable children, and adolescent workforce programs should address any barriers to access related to gender including teenage pregnancy, the needs of young single mothers for daycare, and any discrimination in the workplace.

Sub-Purpose 3: Increased nutrition knowledge and adoption of appropriate nutrition and hygiene practices Development Logic: Stunting rates remain high in Rwanda, at 44% in 2010.12 The persistent high rates of stunting are significant, as malnutrition during fetal development and early childhood is known to have long-lasting negative effects on the individual, including lower school achievement, future health problems, lower income in adulthood, reduced resistance to diseases, and increased levels of mortality.13,14,15 Adults are affected as well: the primary cause of maternal mortality in Rwanda is hemorrhaging, which is related to anemia, and another common cause is eclampsia/hypertensive disorders, which is related to calcium deficiency.16 These negative effects cost Rwanda an estimated 503.6 billion Rwandan francs (equivalent to 11.5% of Rwanda’s GDP) in 2012.17

11 EDPRS 2, Social Protection Strategy, 2013.

http://www.minecofin.gov.rw/fileadmin/templates/documents/sector_strategic_plan/Social__Protection__Strategy__July_2013.pdf 12 National Institute of Statistic of Rwanda (NISR), Ministry of Health (MOH), and ICF International (2012). Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA: NISR, MOH, and ICF International.

13 Martorell, R., Melgar, P., Maluccio, J.A., Stein, A.D., & Rivera, J.A. (2010). The nutrition intervention improved adult human capital and economic productivity. The American Institute of Nutrition, 140(2), 411-414.

14 Grantham-McGregror, S., Cheung, Y.B., Glewwe, P., Richter, L., Strupp, B., & International Child Development Steering Group (2007).

Development potential in the first 5 years for children in developing countries. The Lancet 369(9555), 60-70.

15 Dewey, K.G. & Begum, K. (2011). Long-term consequences of stunting in early life. Maternal & Child Nutrition, 7(s3), 5-18.

16 National Institute of Statistic of Rwanda (NISR), Ministry of Health (MOH), and ICF International (2012). Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA: NISR, MOH, and ICF International.

17 UN Economic Commission for Africa & the World Food Programme (2013). The cost of hunger in Rwanda. The social and economic impact of child undernutrition in Rwanda. Implications on national development and vision 2020. (The study calculates the combined cost of undernutrition by considering the need for extra health care, school repetition and drop outs and diminished productive capacity and mortality.)

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As outlined in USAID’s Multi-Sectoral Nutrition Strategy, malnutrition (including stunting) is caused by a variety of individual, household, community, national, and underlying factors that together determine whether the requisites for healthy growth (food, health, and care) will be met. Effective programming to address malnutrition requires a cross-cutting approach, and while all of CHAIN’s sub-purposes contribute to improved nutritional status, a particular focus on nutrition and hygiene is required. This sub-purpose describes CHAIN’s activities to ensure quality training and services in prenatal health, adequate dietary intake, access to health services and immunization, and adoption of hygienic practices and environments. In addition, CHAIN will support coordination and collaboration among local government, community leaders, civil society, and households. These activities will complement those described in the Feed the Future and SCHS projects.

Output 3.1: Increased food security for vulnerable populations Access to diverse foods depends largely on household income and food availability. In the Rwandan context, calorie availability has paralleled population growth and is sufficient for the population to have 2,100 calories per day.18 However, the supply of high quality protein and fats, and the bioavailability of certain vitamins (B12, B2, and A) and minerals (calcium, iron, and zinc) remains insufficient. One explanation is the limited availability and affordability of foods of animal origin, including milk, eggs, poultry, fish, and meat—even if available, the minimum-cost nutritious diet19 costs 165% of the income of the very poor, 148% of the income of the poor, and 94% of the income of middle income Rwandans.20

CHAIN will work through agriculture and economic growth activities to increase yields of bio-fortified crops and crops that are the main sources of energy and low-cost proteins. In addition, it will promote production, processing, distribution, and commercialization of animal source foods value chains to increase the availability and consumption of animal source protein. CHAIN will also target increased use of food supplements and complementary foods that provide micronutrients missing in the Rwandan diet and can improve maternal nutrition and complementary feeding. CHAIN will pursue partnerships to implement these activities and will collaborate with partners working under the S-TIME Project.

Behavior change communication and advocacy will remain a major activity under this output and will include promotion of animal source foods, biofortified crops, and the use of income-generation circles to promote use of funds to improve familial nutrition status.

Output 3.2: Improved WASH actions to reduce diarrheal disease According to the Rwanda 2010 DHS, the prevalence of diarrheal disease in Rwanda is 13% for all children under five but over 20% for children aged 6-23 months, when children begin complementary feeding and start to come into contact with their environment through crawling. The diarrheal disease burden at this critical developmental time contributes to physical and cognitive stunting and was the cause of 17% of under-five child mortality in Rwanda in 2010.21 Pit latrines, which are the largest category of latrine type used in Rwanda, may meet the Millennium Development Goal definition of “improved,” but they do not prevent exposure to feces. Availability of clean water is also not assured as, sources may be contaminated despite 68% access in rural areas (JMP 2014), access may be complicated by Rwanda’s challenging terrain, and safe transport and storage are not guaranteed.

CHAIN will promote the suite of evidence-based hygiene behaviors that have been shown to reduce

18 MINAGRI Annual Report 2012 19 For the study’s purposes, the authors defined a minimum cost nutritious diet as a “lowest cost diet that meets the average energy and the recommended nutrient requirements of the household” (p.18).

20 Save the Children (2011). A cost of diet analysis in a northern highland district of Rwanda.

21 Child Health Epidemiology Reference Group, 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. The Lancet.

Community Health and Improved Nutrition Project Appraisal Document Page 14 diarrhea in children under five, through CHWs and CSOs/CBOs at community level, as well as through the private sector. Priority hygiene behaviors include hand washing with soap before handling food and after contact with feces, correct and consistent use of hygienic sanitation, and household water treatment and safe storage.22 CHAIN will also promote clean containers and safe transport and storage of water in the household and also continue to promote correct and consistent adoption of water treatment, with SûrEau or other evidence-based water treatment products. In addition, CHAIN will work with CHWs and others to create demand for household investment in new or upgraded latrines, which are easy to clean and cover when not in use.

Finally, although hand washing with soap is the single most effective and inexpensive way to avert diarrhea-related child deaths and disease,23 as measured by disability-adjusted life years (DALYs), a 2013 study by UNICEF indicates that only 28% of caregivers wash their hands with soap before feeding a child or preparing food, despite 100% knowing that they should. Likewise, 64% know they should wash their hands after using the latrine, but only 46% do so,24 and 97% of caregivers do not wash their hands immediately after wiping a child’s bottom. Opportunity for personal hygiene is limited by the fact that only 10% of households have a place for washing hands and 53% lack water, soap, or any other cleansing agent. There are a range of hand-washing station options available, including the “tippy tap,” which is a container made of locally available materials that allows hand washing with a minimal amount of water. CHAIN will build on the work of other USAID partners in promoting a range of tippy taps adapted to the local context and will explore partnerships with soap manufacturer(s) to promote hand washing.

Output 3.3: Improved nutrition behaviors25 Data suggest that dietary diversity (particularly in the mother’s diet and in the food being offered during the complementary feeding period), diarrheal illnesses, and the intake of micronutrients such as iron and zinc by mothers and children remain key areas of concern in addressing Rwanda’s high levels of childhood stunting and anemia. Improved knowledge and practices will also be critical: only 24% of caregivers have knowledge of proper feeding practices for children,26 and recent World Food Program analyses suggest that increased education, particularly completion of secondary school, is correlated with a sharp decline in the likelihood of having a stunted child.

Under this output, CHAIN will leverage the existing CHW structure to improve nutrition and WASH practices. It will strengthen the capacity of CHWs to deliver key nutrition and WASH messages, counseling, and services through ongoing training and support of the CHWs. Critical to improving nutrition and WASH behaviors is ensuring counseling is high quality, reinforced in a timely manner, and supported by the expanded household decision makers and community. CHAIN will also reinforce linkages between CHWs and health facilities to ensure appropriate care and treatment when necessary.

Social and behavior change is critical to decreasing malnutrition. Communication activities will promote demand for key nutrition and WASH products and services and increase optimal nutrition and WASH practices. This output’s activities will include the establishment and support of women’s groups and hygiene clubs and integrate nutrition and WASH messaging into income generation activities, savings and credit groups, farmers groups, and other community networks. Nutrition will

22 Cairncross et al. (2010). Water, sanitation and hygiene for the prevention of diarrhea. Int. J. Epidemiol. (2010) 39 (suppl 1).

23 Cairncross and Valdmanis, (2006). Water Supply, Sanitation and Hygiene Promotion, in Disease Control Priorities in Developing Countries, 2nd edition. Jamison DT, Breman JG, Measham AR, et al., editors. Washington (DC): World Bank; 2006.

24 UNICEF (2013)

25 Data in this section is drawn for the DHS. However, UNICEF (2013) provides relevant and more alarming data such as 38% of caregivers introducing complementary foods at 6 months and only 41% of caregivers knowing that this is the appropriate time to introduce complementary foods. However, the report’s author instructed that the data was not applicable at the national level and recommended relying on the DHS.

26 UNICEF (2013) p.49 http://www.dcp2.org/main/Home.html

Community Health and Improved Nutrition Project Appraisal Document Page 15 also be expanded in the education curriculum.

The project will also build institutional capacity and enable local organizations to access international best practices and technical support in order to decrease malnutrition. The project will also support the GOR via Rwanda’s National Multi-sectoral Strategy to Eliminate Malnutrition, the District Plans to Eliminate Malnutrition (DPEMs), and MINAGRI’s Nutrition Action Plan.

Finally, CHAIN will contribute to the introduction of the GOR’s fortification strategy and monitor its influence in select rural communities. CHAIN will also test the feasibility of fortifying rice, sorghum, and milk, as well as potentially food supplements and/or pharmaceutical products. CHAIN will stimulate the work of national researchers such as those in the College of Science and Technology of the University of Rwanda on relevant topics.

Sub-Purpose 4: Improved performance and engagement by CSOs and GOR entities Development Logic: Amplifying the voice and strengthening the advocacy skills of communities and CSOs can have positive outcomes for health service delivery. CSOs also have an important role in promoting demand creation and health seeking behaviors. A review in Nigeria in 2008 found that involving clients and community representatives in the assessment and monitoring of health service delivery not only gave citizens a voice in the health sector, but also strengthened the formal health system response. The same study also found that the engagement of CSOs was a positive contributing factor.27

This sub-purpose is concerned with strengthening the institutional systems in the GOR, private sector, and civil society that promote access to health products and services, as well as other critical social services that support health outcomes in vulnerable populations. Targeted CSOs will be in an improved position to help the community articulate their health needs and share concerns through existing or emerging formal and non-formal mechanisms. Realization of this result will depend substantially on a successful collaboration between CHAIN and the Democracy and Governance Office’s Human Institutional Capacity Development (HICD) activities and will complement and indirectly support the SCHS project.

Output 4.1: Improved organizational systems, processes, and procedures The establishment and reinforcement of sound organizational systems is critical to the development of local organizations and contributes to their sustainability. Currently, the USAID/Rwanda Health Office provides direct cooperative agreements to four local CSOs and has indirect relationships with many others.

As part of local capacity development objectives under USAID Forward, each of the four direct grantee organizations has already undergone an assessment by the Democracy and Governance Office’s HICD activity, which USAID has invested heavily to strengthen the organizational systems of its direct grant recipients. Under this output, capacity building activities of these four CSOs will continue through tailored capacity building plans HICD developed for each CSO. Areas for development may include strategic planning, monitoring and evaluation systems, or financial planning. In the event that new local CSO awards are made later in the CHAIN project, additional capacity building activities will be developed to support the new local partners.

In addition, many of USAID’s CHAIN implementing partners provide sub-grants to local CSOs and/or CBOs and often provide significant capacity building support for these organizations to improve their operations, and in some cases, support them to become direct recipients of USAID funding.

27 Technical Brief: Strengthening Voice and Accountability in the Health Sector, Cathy Green, PATHS, DFID 2013

Community Health and Improved Nutrition Project Appraisal Document Page 16

Output 4.2: Improved technical capacity in health promotion, care and support of vulnerable populations, and nutrition In order to maximize the role of CSOs within the health and nutrition sectors, it is essential that they have strong technical capacity. Under this output, a number of strategies will be used to increase the capacity of CSO staff and organizations as a whole. For example, this may include support for trainings, study tours, and/or other learning opportunities for technical staff of CSOs. Activities may also include support for the development of technical tools and guidelines that can be used by CSOs and CBOs in health promotion, care and support, and nutrition activities. In addition, CSOs will engage in national technical working groups to improve coordination and alignment with wider health and nutrition sector strategies and activities.

Output 4.3: Improved capacity for and participation in advocacy Local CSOs working with vulnerable populations have a unique role to play in advocacy at the local level. Given their work and long-standing relationships with the community, they are well placed to work with local leaders to ensure that the needs of the most vulnerable are met. For example, the local CSOs can advocate with local leaders for inclusion of identified vulnerable households in social programs or advocate for programs to target specific districts or sectors with identified needs.

Under this output, local CSOs and other partners will receive technical support to increase their capacity to engage in advocacy on behalf of their target populations and to encourage communities to advocate for their own needs. This support will aim to further the other three sub-purposes by helping CSOs to, for example:

● Create space for voice and advocacy between providers, policy makers, and communities, and to raise communities’ awareness of their rights and entitlements to quality health services;

● Engage in formal and non-formal mechanisms through which clients and community members can express their views to reach WASH and health service providers and policy makers;

● Ensure that the voices represent the wider community—including women, youth, and the most vulnerable—and find ways to improve the quality of women’s participation in these processes; and

● Emphasize community participation in health as an entry point and strengthen public participation on health issues.

IV. PROJECT IMPLEMENTATION MECHANISMS

Overview of Project Activities The CHAIN Project will be implemented through approximately 20 activities authorized under this and other USAID/Rwanda PADs, reflecting contributions from across the entire spectrum of USAID/Rwanda DOs. The activities currently awarded or already listed on the USAID Business Forecast are catalogued in the table below.

Current CHAIN Implementing Partners

ACTIVITY NAME IMPLEMENTING

PARTNER

START DATE END DATE TECHNICAL OFFICE

Ubaka Ejo AEE/Rwanda 9/12/2012 9/11/2020 Health Turengere Abana Association François-

Xavier Bagnoud (FXB)/Rwanda

9/12/2012 9/11/2020 Health

Gimbuka Caritas/Rwanda 9/12/2012 9/11/2020 Health

Community Health and Improved Nutrition Project Appraisal Document Page 17

Rwanda Social Marketing Program

Society for Family Health

10/25/2012

10/24/2019 Health

ROADS III FHI 360 10/1/2013 9/30/2016 Health Twiyubake Global Communities 2/1/2015 1/31/2020 Health Global Alliance for Improved Nutrition

(GAIN)

GAIN 3/1/2015 2/28/2018 Economic Growth

Orange Fleshed Sweet Potato (OFSP) Activity

CIP 6/2015 6/2018 Economic Growth

Iron Rich Beans Activity Harvest Plus 6/23/2015 6/23/2018 Economic Growth Tworore Inkoko Twunguke GDA

University of Tennessee Institute of Agriculture

12/1/2016 11/30/2018 Economic Growth

Sugira Muryango GDA Boston College

1/1/2016 1/1/2020 Health

Gikuriro Catholic Relief Services 11/11/2015 11/10/2020 Health Isuku Iwacu SNV 9/1/2016 11/10/2020 Health

Breakthrough Action Johns Hopkins Center for Communication Programs

10/24/2017 10/24/2019 Health

Akazi Kanoze Youth Livelihoods Project

Education Development Center

10/1/2008 6/30/2016 Education (YOUTH)

Huguka Dukore Education Development Center

8/31/2016 8/30/ 2021 Education (YOUTH)

Ejo Heza - Integrated Improved Livelihoods Program (IILP)

Global Communities 7/13/2011 7/12/2016 Economic Growth (S-

TIME)

Rwanda Dairy Competitiveness Project

II (RDCP II)

Land O' Lakes Inc. 1/6/2012 1/5/2017 Economic Growth (S-

TIME)

Human and Institutional Capacity Development

(HICD)

Development Alternatives Inc. (DAI)

4/30/2012 4/30/2017 Democracy and Governance (VOICE)

Private Sector Driven Agricultural Growth (PSD-

AG)

Engility 8/1/2014 7/31/2019 Economic Growth (S-

TIME)

Feed the Future Rwanda Hinga Weze

Cultivating New Frontiers in Agriculture

6/22/2017 6/22/2022 Economic Growth (S-

TIME)

Opportunities for Policy Engagement CHAIN will address five key policy goals and priorities, outlined in the table below. These goals will be conveyed directly by USAID in meetings with government counterparts, as part of donor coordination fora, and in Embassy-led advocacy.

Policy Challenge Policy Goal No common external tariff on nutrition-sensitive items

Lower tariffs on goods that play a key role in stunting reduction and adjusting the tariff scheme to make it more nutrition sensitive

Limited adherence to standards for milk and other raw products of animal origin

GOR implements existing regulations for the safe production, handling, and marketing of raw milk and other raw animal products

Prohibitively high taxation on energy Lower energy project tax rates to increase viability of agricultural projects and promote

Community Health and Improved Nutrition Project Appraisal Document Page 18 improved food security Weak nutrition coordination bodies Develop donor and national nutrition coordination platforms to increase engagement and complementarity among stakeholders;

encourage increased nutrition coordination at the decentralized level

Limited communication between stakeholders in the existing child protection system

Linkages established between PLHIV, OVC, and other vulnerable families to basic health care, as well as to support services that mitigate the impact of HIV, including services education, economic empowerment, and legal protection

Evaluation Plan The CHAIN Evaluation Plan, shown below, corresponds to the life of the CDCS. The developmental value of evaluation will be maximized by integrating evaluation into the design of selected implementing mechanisms. For the selected mechanisms, either USAID or the implementing partner will develop a program of evaluation at the design stage that will schedule some or all of the following:

1. A baseline to serve as a counterfactual based on the intended impact and outcomes of the mechanism;

2. A mid-term review focusing on implementation effectiveness and progress towards outcomes;

3. An end-line evaluation focusing on performance or impact; and

4. Any additional evaluations that may be required during the implementation period.

It should be noted that the evaluation questions included are notional and will be further developed through scopes of work for each evaluation.

CHAIN Evaluation Plan

Activity to be Evaluated

Evaluation Type Evaluation Questions Evaluation Start Date

Evaluation End Date

Turengere Abana, Ubaka Ejo, and Gimbuka

1. Performance (External)

2. Performance (External)

1) How do costs associated with delivering services to OVCs by local organizations compare to those of international organizations?

2) How does quality of services delivered to OVCs by local organizations compare to those delivered by international organizations?

Jan-15

Feb-15

Feb-15

Rwanda Social Marketing Program

Performance (Internal*)

1) How effective are HIV social marketing interventions among MSM and FSWs in Rwanda? What are the factors associated with condom use among these key populations? To what extent are RSMP interventions associated with desired HIV prevention behaviors?

2) How available and accessible are socially marketed products in Rwanda?

3) What are key behavioral factors/determinants of behaviors associated with current use of modern family planning methods among…