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Study Overview

Rwanda Stunting Prevention and Reduction (SPAR) Program Impact Evaluation
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The Rwanda Stunting Prevention and Reduction (SPAR) program was designed by the Government of Rwanda, in partnership with the World Bank, to accelerate the reduction of chronic malnutrition in children under two, with a particular focus on vulnerable households. The SPaR program involves a multisectoral approach addressing the basic, intermediate and underlying causes of stunting. It includes a health system strenghtening component, The Stunting Prevention and Reduction Project, or SPRP, and the provision of cash transfers (CTs) to vulnerable household, as part of the Nutrition-Sensitive Direct Support (NSDS) Strengthening Social Protection component. Out of 30 districts in Rwanda, 13 high-stunting districts were selected by the Government to receive both SPRP and NSDS components. Additionally, 5 districts were selected to be targeted with the NSDS component exclusively. The impact evaluation of the SPaR program addresses a series of research questions concerning the effectiveness of either the overall program or of particular components of the program on primary and secondary outcomes, through a community survey, with a household and community health worker component, as well as a facility-level survey.

Registration Citation:
Health, Nutrition, and Population
Social Protection
Additional Keywords:
Stunting reduction, Early Child Development
Secondary ID Number(s):

Principal Investigator(s)

Name of First PI:
Jed Friedman
The World Bank
Name of Second PI:

Intervention Overview


The SPaR program aims to contribute to the reduction in the stunting rate among children in selected priority districts. The program involves the following components:

1) The Stunting Prevention and Reduction Project, or SPRP, includes different components to address the supply-side of high-impact nutrition and health interventions, including the use of community health workers (CHWs), in 13 districts selected by the Government based on their high rates of stunting, household poverty and food insecurity, out of a total of 30 districts, in Rwanda. The SPRP project also includes support to home-based early childhood education (ECD) and complementary WASH interventions, as well as the distribution of fortified blended foods (FBF) targeting the most vulnerable households.

2) The Strengthening Social Protection (SSP) project, of which the novel Nutrition-Sensitive Direct Support (NSDS) represents the core component targeting malnutrition. The NSDS involves providing cash transfers (CTs) to vulnerable households with soft co-responsibilities for children to participate in growth promotion activities at health centers, and mothers to attend antenatal and postnatal services. This component of the SPP project was originally rolled out in 17 districts (13 of which are targeted for support under the health project (SPRP)) and specifically targeted the most vulnerable households with pregnant women and infants in the 1,000 day window from conception until age 2. The program has since been expanded to an additional district (18 in total).

Theory of Change:

The program will support a wide range of complementary nutrition interventions, overlapping in some geographic areas to maximize synergies and promote convergence that is critical to addressing the multi?sectoral nature of stunting. The program aims to support a community?based approach to the Early Years and stunting reduction goal that empowers and holds accountable local authorities, relies on decentralized structures, and promotes broad based social mobilization and ownership. To this end, the program aims to: (i) increase coverage and quality of high?impact health and nutrition interventions (health) and child caring, feeding and WASH practices (health, social protection, agriculture); (ii) introduce conditional nutrition support grants as a component of the expanded direct support; and gender and child sensitive models of expanded public works (social protection); and (iii) strengthen food security and dietary diversity (agriculture).

The program includes several cross cutting dimensions: (a) behavioral change communications to bring about a paradigm shift in the way Rwandans think about stunting and to improve child caring, feeding, and WASH practices; and promote nutrition?sensitive agriculture practices; (b) targeted support to high stunting districts, poor and vulnerable populations, and the first 1,000 days; (c) service delivery innovations, such as home?based, community?based ECD models; interactive technologies and interoperable information systems for prompt identification of growth faltering; and results?based approaches to enhance accountability at all levels; and a (d) learn by doing approach that will determine what works and how it can be scaled up.  Likewise, the World Bank program places a premium on leveraging successful platforms for delivering services, such as the CHW program, and enhanced local government capacity, which are critical for the effective delivery of services across multiple sectors.

Multiple Treatment Arms Evaluated?

Intervention Timing

Intervention or Program Started at time of Registration?
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Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Difference in difference/fixed effects
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Method Details

Details of Evaluation Approach:

The impact evaluation of the SPaR program plans to investigate: (1) the net impact of the total program effort on the priority outcomes of interest among children under five years of age, with a special focus on children under two years of age for the most vulnerable households and (2) the impact of the nutrition-focused CT on priority outcomes in targeted households, and whether there is a differential impact of the CT on targeted households in the districts not accompanied by the SPRP health system strengthening activities. The primary outcomes for all interventions are height-for-age in children under 2. Secondary outcomes depend on the specific intervention and, in part, will be selected to trace mechanisms through which the intervention operates.

As this overall program extends to 13 purposively selected districts, the evaluation method is quasi-experimental. To determine the net effectiveness of overall program efforts, a difference-in-differences methodology will be employed to contrast changes in the priority outcomes in the population of interest across districts with differential net exposure to the various programs and activities. As the CT is a household targeted program, the evaluation can employ a regression discontinuity design for the second research question, using ineligible households just above the eligibility threshold as a comparison group. To estimate the relative effectiveness of the CT program in areas with supply-side strengthening, the same difference-in-differences of program effectiveness must be estimated, but now for both the 13 SPRP-and-SSP districts and the five non-SPRP-only-SSP districts. These two estimates will then be compared in a triple-difference framework. The possibility of community-level matching on baseline observables across treatment and control districts to improve comparability/precision will also be explored.

Outcomes (Endpoints):

Primary (impact) indicators

  • Height-for-age in under-2s
  • Stunting in under-2s
  • Pregnant women nutrition services
  • Child development score

Secondary indicators

Birth outcomes

  • Birth weight

Health outcomes of non-targeted populations

  • Height-for-age in 2-5 years old
  • Stunting in 2-5 years old

Infant and young child feeding and care practices

  • Infant and young childcare practices
  • Infant and young children feeding practices
  • Utilization of ANC and PNC services
  • Utilization of growth promotion / nutrition services
  • Utilization of preventive services
  • Utilization of additional nutrition services
  • Quality of service delivery
  • Knowledge of child nutrition issues
  • Satisfaction with service delivery

Environmental health

  • WASH, e.g., access to latrines, safe water storage
  • Hygiene and sanitation knowledge and practices

Food adequacy

  • Increased income (to purchase nutritious foods)
  • Enhanced dietary diversity
  • Access to nutritious foods
Unit of Analysis:
  1. The overall program has a net impact on the priority outcomes for children under five years of age, with a special focus on children under two years of age living in the most vulnerable households.
  2. The nutrition-focused CT has an impact on priority outcomes for recipients living in vulnerable households from targeted districts.
  3. There is a differential impact of the CT on targeted households in the districts not accompanied by the SPRP health system strengthening activities.


Unit of Intervention or Assignment:
Number of Clusters in Sample:
Number of Individuals in Sample:
10,142 children under 24 months of age for household survey; 200 health facilities for facility survey
Size of Treatment, Control, or Comparison Subsamples:
5834 children under 24 months of age in treatment districts and 4308 in control districts. 133 health facilities in treatment districts and 66 in control districts

Outcomes Data

1) household survey covering 10,074 households (10,142 children under 24 months old) in 30 districts; 2) community health worker (CHW) survey covering 1,732 CHWs in 30 districts; and 3) health facility survey covering 200 health centers with health worker modules, patient exit interviews and administrative data extraction component.
Data Already Collected?
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Treatment Assignment Data

Participation or Assignment Information:
Data Obtained by the Study Researchers?
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Data Obtained by the Study Researchers?
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Data Analysis

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Study Materials

Upload Study Materials:
Concept Note: SPaR_ConceptNote_12.10.21_Clean.docx

Registration Category

Registration Category:
Prospective, Category 1: Data for measuring impacts have not been collected

Completion Overview

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Preliminary Report:
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Data Availability

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Other Materials

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Description of Changes:

Study Stopped