who country cooperation strategy...who country cooperation strategy 2014‑2018 5 gor government of...

W H O C o u n t r y C o o p e r a t i o n S t r a t e g y 2 0 1 4 ‑ 2 0 1 8 1

2014‑2018

WHO COUNTRY COOPERATION STRATEGY

R W A N D A


Contents

Abbreviation............................................................................................................. 4

Preface...................................................................................................................... 7

Executive summary....................................................................................................8

1. Introduction.........................................................................................................11

2. Health and development challenges and national response ................................13

2.1. Macroeconomic,politicalandsocialcontext.....................................................13

2.2. Majordeterminantsofhealth.............................................................................14

2.3. Healthstatusofthepopulation..........................................................................18

2.4. Nationalresponsestohealthchallenges............................................................21

2.5.Health systems and services..............................................................................21

2.6. ContributionsofRwandatotheglobalhealthagenda.......................................24

2.7. Summary............................................................................................................26

3. Development cooperation and partnerships........................................................28

3.1. Aid environment.................................................................................................28

3.2. Stakeholder analysis...........................................................................................28

3.3. Coordinationandaideffectiveness....................................................................29

3.4. UNReformstatusandCCA/UNDAPprocess.......................................................30

3.5. Summary ...........................................................................................................31

4. Review of WHO cooperation over the past CCS cycle............................................32

4.1. Review process...................................................................................................32

4.2. Frameworkforanalysingpartnerperceptions...................................................32

4.3. Internal review....................................................................................................33

4.4. Summary.............................................................................................................36

W H O C o u n t r y C o o p e r a t i o n S t r a t e g y 2 0 1 4 ‑ 2 0 1 82

5. Strategic agenda for WHO cooperation.................................................................37

5.1. StrategicagendaforGovernmentofRwandaandWHOcooperation...............37

5.2. RwandaCCSstrategicpriorities………………………………………….....………..........…...38

5.3. ValidationoftheCCSstrategicagendawiththethirdHealthSector

Strategic Plan......................................................................................................47

5.4. ValidationoftheCCSstrategicagendawiththeRwandaUNDevelopment

Assistance Plan...................................................................................................48

5.5. ValidationoftheCCSstrategicagendawiththeWHO12thGeneralProgramme

ofWork...............................................................................................................49

6. Implementing the strategic agenda: implications for the Secretariat ....................50

6.1. TheroleandpresenceofWHO..........................................................................50

6.2. UsingtheCountryCooperationStrategy...........................................................51

6.3. Monitoringandevaluation.................................................................................51

References ………………………………………………………………………………….........................… 52

Annexes

Annex 1: Organogram of the WHO Rwanda Country Office.......................................53

Annex 2: List of stakeholders contacted for CCS III development................................56

List of figures

Figure 1: WHO CCS 2014-2018 Rwanda linkages to key national strategic

documents...................................................................................................11

Figure 2: Organization of the Rwanda health sector..................................................22

Figure 3: UNDAP 2013-2018 programme result areas and outcomes.......................30


List of tables

Table 1: Health sector programmes and initiatives, Rwanda..........................................25

Table 2: Alignment of Country Cooperation Strategy and Health Sector Strategic

Plan III...............................................................................................................47

Table 3: Alignment of CCS priorities and UNDAP outcomes and outputs.......................48

Table 4: Alignment of CCS priorities and main focus areas with the WHO 12th GPW

categories, 2014-2019.......................................................................................49


Abbreviations

AEFI AdverseEventFollowingImmunization

AIDS AcquiredImmunodeficiencySyndrome

APOC AfricanProgrammeforOnchocerciasisControl

ART AntiretroviralTherapy

BUFMAR BureaudeFormationsMedicalesAgrééeduRwanda

CCA CommonCountryAssessment

CCM CountryCoordinationMechanism

CCS CountryCooperationStrategy

CDC CentersforDiseaseControlandPrevention(USA)

CFSVA ComprehensiveFoodSecurityandVulnerabilityAnalysisandNutritionSurvey

CHW CommunityHealthWorker

CVD CardiovascularDisease

DFID DepartmentforInternationalDevelopment(UK)

DH DistrictHospital

DHS DemographicandHealthSurvey

DOTS Directly-ObservedTreatmentShort-course

DP DevelopmentPartner

DPCG DevelopmentPartnersCoordinationGroup

EAC EastAfricanCommunity

ECD EarlyChildhoodDevelopment

EDPRS EconomicDevelopmentandPovertyReductionStrategy

EPI ExpandedProgrammeofImmunization

FBO Faith-BasedOrganization

FP FamilyPlanning

GBS GeneralBudgetSupport

GDP GrossDomesticProduct

GFATM GlobalFundtofightAIDS,TuberculosisandMalaria


GoR GovernmentofRwanda

GTZ DeutscheGesellschaftFurTechnischeZusammenarbeit

HC Health Centre

HF HealthFacility

HIS HealthInformationSystem

HIV HumanImmunodeficiencyVirus

HMIS HealthManagementInformationSystem

HRH HumanResourcesforHealth

HRIS HumanResourceInformationSystem

HSSP HealthSectorStrategicPlan

IDSR IntegratedDiseaseSurveillanceandResponse

IHDPC InstituteofHIV/AIDSDiseasePreventionandControl

IT InformationTechnology

JICA JapanInternationalCooperationAgency

JMP JointMonitoringProgrammeofWHO/UNICEF

MCH MaternalandChildHealth

MDG MillenniumDevelopmentGoal

MDR Multi-DrugResistant

MoA MinistryofAgriculture

MoH MinistryofHealth

MOU MemorandumOfUnderstanding

MPPD MalariaandOtherParasiticDiseasesDivision(ofRBC)

MTR Mid-Term Review

NCD NoncommunicableDisease

NGO NongovernmentalOrganization

NHA NationalHealthAccounts

NISR NationalInstituteofStatisticsofRwanda

P4P PayforPerformance

PBF Performance-BasedFinancing

PCT PorphyriaCutaneaTarda


PEPFAR President’sEmergencyPlanforAIDSRelief(USA)

PLHIV Person LivingwithHIV

PMTCT PreventionofMother-To-ChildTransmission

RBC RwandaBiomedicalCentre

RDHS RwandaDemographicandHealthSurvey

REC ReachEveryChild

RTT Resource Tracking Tool

SBS SectorBudgetSupport

SDH Social DeterminantoFHealth

SIA SupplementaryImmunizationActivity

SMS ShortMessageSystem

SOP StandardOperatingProcedure

SRH SexualandReproductiveHealth

SWAp SectorwideApproach

TB Tuberculosis

UHC UniversalHealthCoverage

UNCT UnitedNationsCountryTeam

UNDAF UnitedNationsDevelopmentAssistanceFramework

UNDAP UnitedNationsDevelopmentAssistancePlan

UNFPA UnitedNationsPopulationFund

UNICEF UnitedNationsChildren’sFund

USAID UnitedStatesAgencyforInternationalDevelopment

VCT VoluntaryCounselingand Testing

VPD VaccinePreventableDisease

WCO WHOCountryOffice

WHA WorldHealthAssembly

WHO WorldHealthOrganization


P r e f a c eThird Generation – WHO Country Cooperation Strategy

The WHO Third Generation Country Cooperation Strategy (CCS) crystallizes the majorreformagenda adoptedby theWorldHealthAssemblywith a view to strengthenWHOcapacityandmakeitsdeliverablesmoreresponsivetocountryneeds.ItreflectstheWHO

TwelfthGeneralProgrammeofWorkatcountry level, itaimsatachievinggreaterrelevanceofWHO’stechnicalcooperationwithMemberStatesandfocusesonidentificationofprioritiesandefficiencymeasuresintheimplementationofWHOProgrammeBudget.Ittakesintoconsiderationtheroleofdifferentpartnersincludingnon-stateactorsinprovidingsupporttoGovernmentsandcommunities.

The Third Generation CCS draws on lessons from the implementation of the first and secondgeneration CCS, the country focus strategy (policies, plans, strategies and priorities), and theUnitedNationsDevelopmentAssistanceFramework(UNDAF).TheCCSsarealsoinlinewiththeglobalhealthcontextandthemovetowardsUniversalHealthCoverage,integratingtheprinciplesofalignment,harmonizationandeffectiveness,asformulatedintheRome(2003),Paris(2005),Accra (2008), and Busan (2011) declarations onAid Effectiveness. Also taken into account aretheprinciplesunderlyingthe“HarmonizationforHealthinAfrica”(HHA)andthe“InternationalHealthPartnershipPlus”(IHP+)initiatives,reflectingthepolicyofdecentralizationandenhancingthedecision-makingcapacityofGovernmentstoimprovethequalityofpublichealthprogrammesandinterventions.

The document has been developed in a consultativemanner with key health stakeholders inthecountryandhighlightstheexpectationsoftheworkoftheWHOsecretariat.Inlinewiththerenewedcountryfocusstrategy,theCCSistobeusedtocommunicateWHO’sinvolvementinthecountry;formulatetheWHOcountryworkplan;advocate,mobiliseresourcesandcoordinatewithpartners;andshapethehealthdimensionoftheUNDAFandotherhealthpartnershipplatformsinthecountry.

IcommendtheefficientandeffectiveleadershiproleplayedbytheGovernmentintheconductofthisimportantexerciseofdevelopingtheCCS.IalsorequesttheentireWHOstaff,particularlyWHOCountryRepresentativetodoubletheireffortstoensureeffective implementationoftheprogrammaticorientationsofthisdocumentforimprovedhealthoutcomeswhichcontributetohealthanddevelopmentinAfrica.

Dr Matshidiso MoetiWHO Regional Director for Africa


Executive summary

TheWHOCountryCooperationStrategy2014-2018RwandaoutlinesthemediumtermframeworkforcooperationwiththeGovernmentofRwanda(GoR)throughfivestrategicprioritiesthatwillguidetheworkofWHOinthecountry.TheCCS

2014-2018wasdevelopedthroughaconsultativeprocessinvolvingsystematicassessmentof country needs drawn from the key strategic documents including the EconomicDevelopmentandPovertyReductionStrategyII(EDPRSII2013-2018),theHealthSectorStrategic Plan III (2012-2018), the report on Rwanda’s national consultations on thepost2015developmentagenda2013andUnitedNationsDevelopmentAssistancePlan2013-2018.Consultationswithkeystakeholdersinthehealthsectorprovidedvaluablecontributionstothedocument.Ingeneral,theprocesswasguidedbytheWHOCountryCooperationStrategiesGuide2010.

ItisnoteworthythatRwandahasmadeoutstandingsocioeconomicprogress.Significantimprovements in health outcomes and other key development indicators includingimprovementsinlivelihoodatthecommunitylevelhavebeenobserved.Therealgrossdomesticproduct(GDP)growthaveraged8.2%annuallyduringthepast10years,whichtranslated intoGDPper capita growthof 5.1%per year. Life expectancy at birth hasincreasedfrom51yearsin2002to64.5years(NISR,2013).

Infantmortalityhasdeclinedfrom86/1000livebirths(NISR,2006)to50/1000livebirths(NISR,2010),whilechildmortalitydecreasedfrom153/1000livebirthsin2005(NISR)to76/1000livebirths(NISR,2010).Maternalmortalityratioalsodecreasedfrom750per100000livebirthsin2005to476per100000livebirthsin2010.HIVprevalenceinRwandahasremainedstableoverthelastfiveyearswiththenationalprevalenceat3%amongpeopleaged15-49years.Malariaasthemajorcauseofchildhoodmortalityhasdroppedsignificantlyfromthefirstpositionin2005tothefourthpositionin2012.

Government budget allocation to health as percentage of GoR budget allocated tohealthincreasedfrom7%in2006to13%in2010/11,butthetotalexpenditurerelatedto health as percentageof government total budgetwas 16.05%. Rwandahasmadetremendousprogressintermsoffinancialaccessandriskprotectionbystrengtheningpre-paymentmechanismssuchascommunity-basedhealthinsuranceandotherhealthinsuranceschemes(MoH,2012).

The United Nations is very active as a collaborative partner of the Government ofRwandaandrecentlysignedtheUNDevelopmentAssistancePlan2013-2018tosupport


the implementation and realization of EDPRS priorities.WHO plays a leading role inimplementingthehealthresponseoftheUNDAPinpartnershipwithotherUNagencies.

Despite the significant gains and improvements recorded, concerns still exist thatcoverageofsomeessentialservicesis limitedforsomevulnerablepopulationgroups.Malnutritionisstillanimportantproblemamongchildrenagedunderfiveyearswiththeprevalenceofstuntingremainingashighat44.2%(NISR,2010).TheburdenofmalariainRwandahastransitionedfromanationwidetoalocalproblemmostlyinfivehighburdendistrictsalongtheeasternborderwhichaccountforover70%ofthemalariaburden.The successachieved in the reductionof communicablediseases isbeing challengedby the increasingburdenofnoncommunicablediseases.Severalcommunities remainvulnerabletoclimatechange,epidemicsanddisastersduetofloods,foodinsecurityandpotentialdisplacement.

ThecountryhasimplementedcommendableactionstoaddressissuesrelatedtosocialdeterminantsofhealthwithreferencetotheRio+20politicalrecommendationsincludingthe development of the social protection action plan 2011. The Ministry of HealthSocialClusterhasbeenactivelyimplementingidentifiedsocialprotectioninterventions;however,intersectoralcooperationneedstobeimprovedtogenerateexpectedresults.

During implementationofHSSPII, thecountryrecordedhealthsystemimprovementsduetoachievementofthefollowingstrategicobjectives:(i)improvementofaccessibilityandqualityofMCHservices;(ii)consolidation,expansionandimprovementofservicesforthepreventionofdiseaseandpromotionofhealth;(iii)consolidation,expansionandimprovementofservicesforthetreatmentandcontrolofdiseaseandbystrengtheningthe following programme areas: institutional capacity, human resources, financialaccessibility (health insurance schemes), geographical accessibility (construction,renovation and extension of health facilities), medicines supply (procurement anddistribution),qualityassuranceofhealthservices,specializedservices(MoH,2011).

GiventhereviewofCCS2009-2013andthenationalhealthanddevelopmentchallengesidentified,thefollowingfivestrategicprioritieshavebeenidentifiedtoguidetheCountryCooperationStrategy2014-2018:

a. Supporthealthsystemstrengtheningtowardshealthserviceintegrationanduniversalhealthcoverage;

b. Contributetothereductionofmorbidityandmortalityfrommajordiseasesand thus contribute to the achievement of health-related MillenniumDevelopmentGoals;


c. Contribute to the reductionofmaternal,newbornandchildmorbidityandmortality;

d. Promotehealththroughaddressingsocialdeterminantsofhealth,healthandenvironment,nutritionandfoodsafety;

e. Strengthendisasterriskmanagement,epidemicandemergencypreparednessandresponse,andimplementationoftheInternationalHealthRegulations.

When outlining the strategic priorities, consideration was given to WHO existingcomparativeadvantagesandcorefunctionsashighlightedinthe12thGeneralProgrammeofWork(GPW)including:

a. Providingleadershiponmatterscriticaltohealthandengaginginpartnershipswherejointactionisneeded;

b. Shapingtheresearchagendaandstimulatingthegeneration,translationanddisseminationofvaluableknowledge;

c. Setting norms and standards as well as promoting and monitoring theirimplementation;

d. Articulatingethicalandevidence-basedpolicyoptions;

e. Providing technical support, catalysing change, and building sustainableinstitutionalcapacity;

f. Monitoringthehealthsituationandassessinghealthtrends.

TheWHOCountryOffice inRwandawillbe strengthened to support implementationof the agenda asdefined in Section5of this document.Human resourceswill focuson improving thenumber andensuring adequate skills and capacitiesexisting in theCountryOfficetofacilitateimplementationofthisstrategicagenda.

TheCCS2014-2018 shall beused to guideworkplandevelopmentover thenextfiveyears.Theoperationalplansshallbeguidedbytheprinciplesofefficiency,equityandeffectivenessandwillfocusonachievingresults.Areviewandmonitoringmechanismsshallbeput inplace.Amid-termreviewoftheCCS2014-2018shallbecarriedout inpartnershipwithstakeholderstoreviewprogressandensurecontinuedalignmentwithnationalpriorities.


1 . Introduction

TheWHOCCS2014-2018outlines themediumtermframework forcooperationwith the Government of Rwanda (GoR). Five strategic priorities have beendeveloped toguide theworkofWHO in thecountry.ThefirstCCS forRwanda

coveredtheperiodof2004to2007;thesecondCCScoveredtheperiod2009–2013;andthenewCCSwillcovertheperiod2014to2018.

Ingeneral,theCCS2014-2018articulatesaclearvisionofhowtoimprovethequalityofWHOworkinRwandawiththeaimofprovidingthemaximumcontributiontoimprovethehealthstatusofthepopulation.TheCCS2014-2018articulatesthehealthprioritiesinthecountrytoguideWHOsupportinaccordancewiththeWHOmandateandcorefunctionstoresultinastrongerimpactonhealth.

The CCS 2014-2018 is aligned to the EDPRS II (2013-2018), the HSSP III, the UnitedNationsDevelopmentAssistancePlan(UNDAP)(2013-2018)andotherimportanthealthsector strategic documents. In addition, the CCS reflects priorities identified in theWHO12thGeneralProgrammeofWork2014–2019approvedbytheSixty-sixthWorldHealthAssembly in2013.Activities,monitoring indicatorsand required resources forimplementationof identifiedprioritiesof theCCSaredetailed in theWHObienniumworkplansapprovedjointlybyWHOandtheGovernmentofRwanda.

Figure 1: WHO CCS 2014-2018 Rwanda linkages to key national strategic documents

EDPRS 2

2013‑2018

HSSP II (July 2012‑June 2018) plus other

government guiding documents

UNDAP

2013‑2018

WHO 12th General Programme of Work

2014‑2019

ThedevelopmentoftheCCS2014-2018was ledbyataskforcethatwasguidedbyaroadmapjointlydevelopedbytheMinistryofHealthandtheWHOCountryOffice.Theprocessincludedadeskreviewofrelevantdocumentsandreviewof theimplementationoftheCCS2009-2013.Thereviewalsoinvolveddatacollectionusingaquestionnaireand


conductingin-depthinterviewswithdifferentcategoriesofstaffintheMoHandotherstakeholdersinthehealthsector.Consultationmeetingswereorganizedwithselectedkey agencies within the Government of Rwanda, the United Nations Country Team,developmentpartnersandkeyacademicinstitutions.TheCCSconsultativeprocesswasdrivenby theprinciplesof countryownership to reflectexpectationsof theGoRandotherstakeholdersinthehealthsectorandWHO.Reflectively,theprocessofdevelopingtheCCSwasguidedbytheWHOCountryCooperationStrategiesGuide2010.

Introduction


2. Health and development challenges and national response

2.1. Macroeconomic, political and social context Rwandatodayhasavibrantdemocracywithtransparentgovernanceandaparliamentarysystem that prides itself on the fact that 56.3% of parliamentarians are women.Transparencyandstrongdecentralizationhavesupportedagovernmentnearertothepeopleandhavelaidthefoundationforastrongdistrict-basedsystem.Inaddition,thecountryexperiencedasteadyeconomicgrowthfrom2003to2013of6.5%.

Based on the country vision, the Rwanda health sector has established governancestructuresatcentralandlocallevelscomplyingwiththeprincipleofcountryownership.Inaddition,considerationisgiventothevoiceofcitizensandcommunityparticipationinorder to increaseaccountability. TheNationalDecentralizationPolicywasadoptedwith the overall objectives of (i) ensuring equitable political, economic, and socialdevelopment throughout the country; and (ii) making the district the centre of thedevelopment trajectory in order to reduce poverty. The Policy defines three phasesof implementation. The first phase (2001-2005) aimed at establishing democraticallyelected and community development structures at the local government level. Thesecondphase(2005-2010)aimedatconsolidatingprogressonnationalpriorities.Thethird phase aims to strengthen local governancewith a focus on financial and fiscaldecentralization. Joint health sector review serves as a forum for all health sectorstakeholderstodiscusspriorities,strategizeandmonitorsectorperformance.

Rwanda is a landlocked countrywith anestimatedpopulationof 10.5million; 48.2%aremalesand51.8%arefemales;and51.7%ofallRwandansareundertheageof20years (NISR,2012).With416 inhabitantspersquarekm,Rwanda is themostdenselypopulatedcountryinAfrica,and16.5%ofthepopulationliveinurbanareas.AccordingtotheRwandaPopulationandHousingCensus2012,thelifeexpectancyatbirthis64.5years;theaveragepopulationgrowthratewas2.6%fortheperiod2002-2012;thecrudebirthrateis30.9per1000people;thecrudedeathrateis7.7per1000people,downfrom14.6per1000populationin2002;thetotalfertilityrateisfourchildrenperwoman.


Duringthelasttenyears,Rwandahasexperiencedoneofthemostexcitingandfastestperiodsofgrowthandsocioeconomicprogressinitshistory(MFEP,2013a).PopulationgrowthisstabilizingandthecountryismakinggreatstridestowardsachievingtheMDGsandmiddleincomestatus(MECF,2000).TherealGDPgrowthaveraged8.2%annually,andpercapitaincomeisUS$644whichmeansaGDPpercapitagrowthof5.1%peryear(MFEP,2013a,b).

Theagriculturesectoriswidelyregardedasthemajorcatalystforgrowthandpovertyreduction. In themost recentperiodbetween2002and2012, theagricultural sectoraccounted for 72.7% of the national workforce while the non-agricultural sectorswere27.3%.Thisisaboutafour-foldincreasefromthe7.5%figurethirtyyearsagoforworkforceemploymentinthenon-agriculturalsectors(NISR,2013).

2.2. Major determinants of healthIncome distribution and poverty

Althoughpovertydecreasedmoreinruralareasthanurbanareasin2008-2011,povertyin rural areas still stands at 48.7% compared to 22.1% in urban areas (NISR, 2012).Rwanda’spovertyprofileindicatesthatwomenaremoreaffectedbypovertythanmen;47%offemale-headedhouseholdsarepoor.Improvedincomelevelsresultedinreducedincome inequality.TheGini coefficient,a conventionalmeasureof income inequality,declined from 0.52 in 2005/06 to 0.49 in 2010/11, below the 2000/01 level (0.51).Nevertheless, persistent inequality betweenmen andwomen in accessing economicresourcesremainsoneofthemainchallengesinaddressingruralpoverty(MFEP,2013a).

High growth rates combined with stabilizing population growth has contributed topoverty reduction. The poverty headcount ratio declined from 56.7% in 2005/06 to44.9% in 2010/11with significant poverty reductionexperiencedparticularly in ruralareaswheretheratefellfrom61.9%to48.7%(NISR,2011).

Thereductioninpovertywassupportedbyacombinationoffactorsincludingimprovedagriculturalincomeswheretheshareofmarketedagriculturaloutputsincreasedfrom21.5%to26.9%(2006-2011);a50-60%increase inoff-farmjobcreation;reduction inhouseholdsizesaswellaspublicandprivatetransfers(NISR,2013).

Education

DuringEDPRSI,thelarge-scale,innovativeandcost-effectivenine-yearbasiceducationprogrammewasasignificantachievement infacilitatingaccessofallchildrentobasiceducation. The nine-year programme was internationally recognized, winning the

Health and development challenges and national response


Commonwealth Education Good Practice Awards for 2012. The national primarylevelenrolment ratecontinues to improve forbothgirlsandboysand,at96.5%,hassurpassedthe2012targetof95%.Ifprogresscontinues,RwandawillbeontracktomeettheMDGtargetof100%netenrolmentby2015.Thenationalenrolmentrateforgirls(98%)remainshigherthanforboys(95%).Theprimaryschoolcompletionrateindicatorhasreached72.7%whichisasignificantimprovementonthebaselinefigureof52.5%in2008butstillfallsshortofthe2012targetof78%(NISR,2013).

Health promotion

HealthpromotionisanimportantcomponentofthenationalHSSPIII.Effortstoaddresssocialdeterminantsofhealthandsocialprotectionissuesarealsotopnationalpriorities.The country has developed relevant policies and strategic documents including theSocial Protection Strategy Action Plan 2011, Health Promotion Policy and Strategy,SchoolHealthPolicy,NationalFoodandNutritionPolicyandStrategicPlan.Thenationalstructureforhealthpromotionfromvillagetonationalleveliswellestablished,andacoreteamisnowfunctionalatdistrictlevel.TheMinistryofHealthandotherministriesare implementing identified social protection interventions. However, the nationalauthorities recognize the need to enhance intersectoral cooperation to improve andgenerateexpectedresults,especiallythetranslationofnationaldecisionstothe locallevels.

Nutrition

Acute malnutrition in children aged under five years has improved in Rwanda withalmosta50%reductionfrom5%in2005to2.8%in2010(NISR,ORCMacro,2006,2011).However,stuntinginthesameagegroupremainshighwithanationalaverageof44.2%ofwhich17%areseverecases.Asimilarpictureisseenwithanaemiainchildrenunderfive andwomenof reproductiveagewhere38.1%of children6-59months and17%womenof reproductive age are anaemic (NISR,ORCMacro, 2011). During the samereporting period, the prevalence of womenwho are overweight or obese increasedfrom11.5%to16.3%(NISR,ORCMacro,2006,2011).Nationalstudiesshowthat78%ofchildrenbetween12and24monthsreceivelownutrientdiets(NISR,MoA,WFP,2012).

The multiple causes of the high rates of chronic malnutrition in children and othernutritionproblemsalsoincludeinadequatehouseholdfoodsecuritythataffectsmorethan20%offamiliesinRwanda.Theseproblemsareoftencomplicatedbythesynergyofnutritionwithchildhoodinfections.AsignificantfeatureinRwandafrom2008to2012wastheconsistentandsustaineddecreaseinthechildhoodkillerdiseasesofmalaria,pneumonia anddiarrhoeaespecially among childrenagedunderfiveyears. TheGoR



iscurrentlyimplementingnationally-scaled,community-based,district-drivennutritioninterventionsincludingthenationalcampaignonthefirstthousanddaysofachild’slifeaspartofhighimpactinterventionstoeliminatemalnutritionamongchildren.

Environmental determinants

InRwanda,themainareasofenvironmentalhealthservicesarehygieneandsanitation;waste management; hazardous and toxic chemicals management; food quality andsafety;waterqualitymanagement;watersupply;airqualitymanagement;community-based environmental health promotion programme; occupational health and safety;public health adaptation to climate change; environmental health intervention inemergenciesanddisasters.

The latest estimates from theWHO/UNICEF JointMonitoring Programme forWaterSupplyandSanitationputRwandaontrackforsanitationandnotontrackfordrinkingwatertomeettheMDGtarget.AccordingtotheJointMonitoringProgrammereport,64%ofthenationalpopulationhaveaccesstoanimprovedsanitationfacilitynotsharedbytwoormorehouseholds,while71%haveaccesstoanimprovedwatersource(WHO,UNICEF,2014).

Accordingtothedemographicandhouseholdsurveyof2010,74%ofhouseholdshaveaccesstoanimprovedsourceofdrinkingwater.Themostcommonsourceofdrinkingwater used by the households is protected springwater,which accounts for 38% ofusage, followedby public tap/standpipe (26%).Only 5%of households have runningwater in their dwelling or courtyard; 25% of households use unimproved sources ofwater(NISR,ORCMacro,2011).

Concerning sanitation facilities, 55% of households have access to an improved pitlatrinewithslabthatisnotsharedwithotherhouseholds.However16%ofhouseholdsuseanimprovedpitlatrinewithslabbutsharethelatrinewithotherhouseholds;26%ofhouseholdsuseanunimprovedfacility;and1%ofhouseholdshavenolatrinefacilityatall.Only1%ofhouseholdshaveaplaceforhandwashing.Amongthosehouseholds,21%havewaterandsoapforhandwashing(NISR,ORCMacro, 2011).

Gender

In terms of gender equality, Rwanda has continued to register progress. Women’srepresentation in decision-making positions makes Rwanda the world leader in theproportion of women in parliament (56.3%). In addition, a conducive policy andlegal framework formainstreaminggender insocioeconomicsectorsatall levels is in



place (existenceofanationalgenderpolicy, familypolicy,gender-basedviolence law,inheritancelaw,landlaw,familylaw).Pro-poorandgenderfriendlyprogrammessuchasGirinkawereinitiatedaswellasgendermainstreamingprogrammesandprojectssuchastheGenderResponsiveBudgetingInitiative(MFEP,2013a).

Risk of epidemics and vulnerability to disasters

WithitsgeographicallocationintheGreatRiftValleyneartheNyiragongovolcanoesandtheeffectoftheInterTropicalConvergenceZoneonthecontinent,Rwandaisvulnerableto natural disasters emanating from climatic or seismic disturbances. Some of thesedisasters include drought, torrential rains, floods, landslides, earthquakes, volcaniceruptionsandepidemics.Inthepasttenyears,thesedisastershaveoccurredthroughoutthecountry.Suchdisastersareexacerbatedbypoorfarmingpractices,deforestationandenvironmentaldegradationamongothers.

Historicalanalysisshowsthatfloodsanddroughtshavecausedthemostseriousdisastersinthecountryintermsofthenumberofpeopleaffected.Floodingandlandslidesarehazardsthatfrequentlyaffectlocalizedareasofthecountry.Thehillytopographyandhighannualprecipitation rates,overexploitationof thenatural environment suchasdeforestation and inappropriate farming on steep slopes, and climate change canincrease the disaster risks. These risks result in loss of lives,malnutrition and otherhealthconsequences,disruptiontohealthservicesanddamagetohospitalsandotherproperty(MinistryinchargeofDisasterManagementandRefugees).

Thedisasterprofileincludesdroughts,fire,floods,earthquakes,landslides,heavyrain,trafficaccidents,diseasesandepidemics.Thesedisruptpeople’s livesandlivelihoods,destroy infrastructure and interrupt economic activities; such disasters can retardplanneddevelopmentinhealthandothersectors.

Thecountryhasoftenfacedoutbreaksofepidemicsincludingemergingandre-emerginginfectiousdiseasessuchasInfluenzaA(H1N1),cholera,epidemictyphusandmeningitis.The country has been implementing Integrated Disease Surveillance and Response(IDSR) since 2000 and the system is operational at East African Community level.Guidelinesandmechanismshavebeendevelopedtoaddresshealthemergencies,whileepidemicpreparednessandresponseinterventionshavebeenputinplaceinlinewiththeInternationalHealthRegulations.

MajoreffortshavebeenmadeatnationallevelincludingthecreationoftheMinistryinchargeofDisasterManagementandRefugees(MIDIMAR).Thegovernmenthasendorseddisastermanagementpolicyandstrategies;atthesametime,multisectoralpreparedness



and responsemechanisms have been put in place to strengthen coordination in thecountry.Intheorganizationalframeworkfordisasterriskmanagement,theMinistryofHealthisamemberoftheNationalDisasterManagementSteeringCommitteeandistheleaderofthehealthclusterduringemergencysituations.

2.3. Health status of the populationOverthelastdecade,Rwandahasrecordedsignificantimprovementsinhealthindicators.Crudedeathratewasreducedfrom14.6to7.7/1000peopleandlifeexpectancyrosefrom51.2to64.4years(NISR,2013).Maternalmortalityhasbeenreducedby75%from1071/100000livebirths(NISR,ORCMacro,2006)intheyear2000to340/100000livebirthsin2013(WorldHealthStatisticsReport2013).Childmortalityhasbeenreducedbyover66%from153/1000livebirthsin2005to54/1000in2012,whilethetargetwas51/1000.

HIV and AIDS

HIVprevalence inRwandahasremainedthesamesince2005.Accordingtothe2005and2010RDHSs,atnationalleveltheHIVprevalenceaverageis3%forwomenandmenaged1549years.HIVprevalenceis3.7%forwomenand2.2%formen.HIVprevalenceisthreetimeshigherinurbanareas(7.1%)thaninruralareas(2.3%).HIVestimatesvarybyage,withHIVprevalencehighestamongwomenaged35-39(7.9%)andmenaged40-44(7.3%);prevalenceis51%amongcommercialsexworkers.

Across the country 97% of health facilities offer ART and PMTCT services, and ARTcoverageofexpectantmothersis91.6%.ThenumberofpatientsonARTincreasedfrom19058 in2005 to133942 in June2014 (TracNetReport June2014).TheamountofPMTCTtransmissionat18monthsafterbirthhasdecreasedfrom9.1%(Tracnet2007-2008)to1.9%(TracNetReportJune2014).

Malaria

In2005,malariawasrankedthenumberonekillerofchildrenagedunderfiveyears.Themortalityrateduetomalariahasdecreasednearly85%(Farmeretal,2013).Forthepasttenyears,integratedandcoordinatedeffortshaveincludedacombinationofprevention,diagnosis, treatmentandvector controlactivitieswitha strongemphasisoncapacity-buildingandstrengtheningthehealthsystemincludingcommunityhealthworkers(CHWs).



Tuberculosis

The current TB prevalence is 114/100 000 people (TB prevalence survey 2013). Thenotificationratein2008was89per100000population(allforms)and48per100000peopleforsmear-positivecasesand72.2and41.4per100000forallformsandforsmear-positivepulmonaryTB,respectively(newcasesandrelapses)in2010.TBmortalityratehasbeenreducedby78%overa3-yearperiod(1997-2010).TBtreatmentsuccessrateis89.3%whilethesuccessrateforMDR-TBis93.9%(RwandaBiomedicalCenterannualreportjuly2013-june2014).ForMDR-TB,themortalityratebeforetreatmentdecreasedfrom15%in2008to4.4%in2010suggestingthatdiagnosisofMDR-TBisbeingdoneearlier,inparticularthroughmolecularrapidtests.

HIVtestingamongTBcaseshasalsoincreasedfrom45%in2004to98%in2012.ARTinitiationamongTBandHIVco-infectedpatientsincreasedfrom45%in2005to91%inJune2014(RwandaBiomedicalCenterannualreportjuly2013-june2014).

Vaccine preventable diseases

Routineimmunizationcoverageismorethan95%forallantigens,andfullyimmunizedchildrencoverage is94%(National ImmunizationSurvey2013).Currently12vaccinesare being utilized in the Rwanda routine immunization programme. Due to the highpercentage of coverage in the routine immunization programme as well as periodicsupplementary immunization activities (SIAs), vaccine preventable diseases (VPDs)havebeendrasticallydecreased.Thelastcaseofwildpolioviruswasnotifiedin1993,andneonataltetanuswaseliminatedin2004.RwandaisintheprocessofintroducingmeasleseliminationmodeofsurveillanceinordertomeettheMDGtargetfor2020.

Neglected tropical diseases

Neglected tropical diseases (NTDs) are themost common infections of poor peopleworldwide. In Rwanda, 65.8% of school children are affected by soil-transmittedhelminthes (STHs), the second most frequent problem in health clinics, followingrespiratoryinfections(MoHAnnualreport,2012).Inthepasttwoyears,theMoHandpartnershavebuiltthefoundationforaninitiativetosubstantiallyreducethediseaseburdenofNTDs.ThecountrywasmappedformostPCTdiseases(STH,schistosomiasis,lymphaticfilariasis,trachoma)aswellasonchocerciasis(APOC,1999).

Noncommunicable diseases

Thecountryisexperiencingincreasedincidenceofnoncommunicablediseases(NCDs)suchascardiovasculardiseases,diabetes,chronicrespiratorydiseases,cancerconditions,injuriesanddisabilitiesasthelifestylesandageparametersofthepopulationchange.



AccordingtotheRwandaNCDscountryprofile,NCDsareestimatedtoaccountfor30%ofalldeaths.

BasedonnationalHealthManagementInformationSystem(HMIS)data,in2013NCDsaccountedfor51.9%ofalldistricthospitaloutpatientconsultationsand22.3%ofdistricthospitalhospitalizations(HMIS,2013).Apopulationbasedsurveyonadults15-64yearswasconductedin2012-2013inordertohighlighttheriskfactorsofselectedNCDsinRwanda.Theprevalenceofthemainriskfactorsaretobaccouse(12.9%),unhealthydietandphysicalinactivity(21.4%),harmfulalcoholconsumption(23.5%),injury(34.4%)andobesity (16.1%) (STEPSstudy2013).Currently,preventionandmanagementofmajorNCDsarehinderedbychallengessuchaslimitedskilledpersonnel,expensiveadvancedNCDtreatmentandanineffectivemultisectoralcoordinationmechanism.

Mentalhealthproblemsasconsequencesofthe1994genocideconstituteatoppriorityinthehealthsector.Themainmentalhealthdisordersareepilepsy(52%),psychiatricdisorders (18%), psychosomatic disorders (12%), neurological disorders (8%), variouspsychological disorders and other conditions. (Rwanda Biomedical Center annualreport, july2013-june2014).Although thegovernmenthas integratedmentalhealthwith primary health care, there is still a need to strengthen collaboration betweengovernmentandcivilsocietyinordertoaddresstheissuesofpsycho-activesubstanceabuse,psycho-traumaandpsychosocialproblems inchildrenandadolescents (HealthSectorPolicy2014).

Maternal and child health

RwandahasmadesignificantprogresstoachievetheMillenniumDevelopmentGoals.ThecountryhasachievedMDG5relatedtoreductionofmaternalmortalityby75%in2015.ThecountryisalsoontracktoachieveMDG4relatedtoreductionofchildmortalitybytwothirdsin2015.Childmortalitydecreasedfrom153/1000livebirthsin2005to54/1000livebirthsin2012,whilethetargetwas51/1000.

Accordingtovariousreports,Rwandaisrankedfirstamongcountriesthathaveshownsignificant progress in meeting the health-related MDGs. Although infant and childmortalityrateshavefallendramatically,reducingneonatalmortalityremainsachallenge.The countryhas recordedprogress in reducing theprevalenceofwasting in childrenagedunderfiveyears.Keycontributingfactorsforincreasedcognitivedevelopmentaswellasreducedchildmorbidityandmortalityincludeeffortsforpreventionofchronicmalnutritionand related stunting in children; capacity-building indistricts to addresshumanrightsandequityissuesatprimaryhealthcarelevel;strengtheningcommunityparticipation; and strengthening capacities fordeliveringquality integratedmaternal,newborn,childandadolescentservicesatfacilitylevel.



2.4. National responses to health challenges TheGovernmentofRwandahasusedVision2020tosetlong-termtargetsforcountryplanningandpolicydevelopment.TheEconomicDevelopmentandPovertyReductionStrategy(EDPRS)isafive-yearstrategicplanalignedtoVision2020andMDGsinordertoacceleratethecountrydevelopmentagenda.ThecountryiscurrentlyimplementingtheEDPRSII(2013-2018).Thehealthsectorhasdevelopedpolicyandastrategicplan(HSSPIII)thatarealsoalignedtoEDPRSIIintermsofprioritiesandinterventions.Healthchallengesareaddressedaccordingtotheguidingprinciplesofthehealthsectorpolicyandstrategicplanwhichincludeapeople-centredapproachaswellasintegratedandsustainableservices.

At the international level, the most important policies and commitments providingdirection to the HSSP III are the MDGs, the Abuja Declaration, the African HealthStrategy (2007–2015), the Paris Declaration on aid effectiveness (2005), the AccraAgenda for Action (2008) and theOuagadougouDeclaration on PrimaryHealth Careand Health Systems in Africa (2008). More recent developments have strengthenedMoHpoliticalcommitmenttoreducehealth inequities;these includetheRioPoliticalDeclarationonsocialdeterminantsofhealth(October2011),theBrazzavilleDeclarationonNCDs(2011),theUniversalHealthCoverageDeclaration(2012),theGlobalStrategyforWomen and Child Health Declaration (2014), NCDs countdown (WHA 2012), theAlgiersDeclarationonhealthresearch(2008),and ImplementationoftheFrameworkConventiononTobaccoControl(2005).

2.5. Health systems and servicesThehealthsysteminRwandaisapyramidalstructurewithfivelevels:national,district,sector,cellandvillage.ThehealthsectorisledbytheMoH,which,throughtheRwandaBiomedicalCentre(RBC),supports,coordinatesandregulatesallinterventionsaimedatimprovingthehealthstatusofthepopulation.Servicesareprovidedatdifferentlevelsofthehealthcaresystem(community,healthpost,centre,districthospitalandreferralhospital;seeFigure2)andbydifferenttypesofproviders(public,FBO,private-for-profit,NGOsandtraditionalmedicine).Atthedecentralized, local level,thedistrictoverseesandcoordinatesthelocalimplementinginstitutionsincludinghealthfacilitiesanddistrictpharmacies. Local administrationentitiesplay an important role inhealthpromotionand prevention. The government recognizes the need to address existing disparitiesandhasinstitutedseveralinterventionstoimprovethesituation.Forexample,theP4P(pay forperformance) initiativehasbeenpromoted to improve sexual,maternal andreproductivehealthoutcomesacrossthecountry.



TheMoHiscloselylinkedtotheotherlineministriesandspecificallythoseinthesocialcluster including ministries of education, local government, agriculture, gender andfamily promotion. This linkagemeans that integrated cross-cutting health-based andrelatedprogrammesareimplementedjointlywithenhancedresults.Importantamongtheseisthemultisectoralapproachtonutrition.

Figure 2: Organization of the Rwanda health system

Health financing system Overthelastfewyears,Rwandahasdevelopedacomprehensivefinancingframeworkforhealthsystemsbasedonbestpracticesinglobalhealthcarefinancing.Thisframeworkconsidersboth supply anddemand.On the supply side, there is the implementationof fiscal decentralization with increased transfers from central government to localgovernments and peripheral health facilities on the basis of needs and performanceaswell as a health insurance system including cross-subsidies from richer to poorercategories. On the demand side, there are direct payments to the populationthrough in-kind incentives. A lot of effort has been made to reduce the burden ofout-of-pocket payments. In the last ten years, Rwandamade exceptional progress inprotectinghouseholdsagainstcatastrophichealthexpenditures.Generalout-of-pocketexpendituresdroppedfromUS$9.5in2006toUS$4.09in2010(NISR,2011).

Health information management

Currently,theRwandaMoHisconductingaseriesofreformsinitshealthmanagementinformationsystems.Thesehaveincludedachievementsintheautomationofsystems(R-HMIS, SISCom, RapidSMS, LMIS, IHRIS, Blood transfusion, Tracnet, RTT) that are

ReferralHospital

(5)

Physician Specialists(166)

Physicians GPs (528)

General Nurses (8,973)Midwives (631)

CHWs(45,011)

District Hospital(42)

Heath Center(469)

Community Level(14,837 villages)

~80% of burden of disease addressed at this level



operational atdifferent levels and incorporatean innovativemixofpaper-basedandelectronicsolutions.ThesectorhasimprovedthereportingcomplianceforHMISandisaddressing issuesofdataqualityby introducingstandardizeddataqualityassessmentmethodologyatnationalanddistrictlevels.

The GESIS platform which was formerly used for health facility reporting has beenreplacedbythedistricthealthinformationsystem(DHIS-2).Thereareeffortsunderwayto establish a national health observatory at the request of theMinister of Health.Theobservatory is expected to complement existinghealth informationplatforms tostrengthennationalhealthinformationsystems.TechnicalsupportisbeingprovidedbytheAfricanHealthObservatory.Afive-yearroadmapforaccountabilityandinformationon maternal and child health has been developed. Rwanda completed a nationalpopulationcensusin2012,andtheUNissupportingasetofsurveysincludinganewRDHS2015.Thereareongoingeffortstoimprovequalityofinformationincludingdataonhealthdisparities.

Human resources for health

Althoughthecommunityhealthcentreisthefirstlevelofhealthcareserviceatcommunitylevel, the community health worker (CHW) is a non-professional cadre approved toprovidebasicservicesasdeterminedbytheMoH.From2008to2013,thenumberofpublichealthprofessionalsincreasedfrom11604to12012withhealthmanagersandotherhealth supporting staffamounting to23.3%of all totalHRH.Rwandahad0.02physiciansper10000populationin2005withahealthfacilityutilizationrateof47%.Atpresent,theutilizationrateofhealthservicesandfacilitiesis95%.Theratioofphysiciansper10000populationincreasedmarkedlyto0.6in2013(NationalHRHpolicy2014),butthereisstillapressingneedforincreasedquantityandqualityofhealthprofessionalstoensuredeliveryofqualityhealthservices.

AccordingtotheDecember2011MoHHRISreport,specializedphysiciansrepresentasmallportion(28.3%)ofthetotalphysiciansinclinicalpracticeinthecountry.Additionally,theyaremainly located inandaroundthecapitalcityKigali,whereas80%ofgeneralpractitionersaredistributedindistricthospitalsintheruralareas.Thisconcentrationofspecialistscreateslimitationsinexpertiseavailabletothecommunityinruralhospitalsduringtimeofneed.

Theproblemsof shortageandperformanceofHRHstill exist and thishasdirectandindirect impacts on thequality of service delivery. TheMoHhas been implementinginnovative interventions including P4P to enhance health workers’ motivation andperformance.



In addition to the strategic plan developed in 2012, the MoH has developed theNationalHumanResourcesforHealthPolicy.RelatedHRHsustainabilitystrengtheningand motivational strategies are under development; they are designed to addresscomprehensivechallenges.TheMoHhasalsoinitiatedinterventionstoimprovehealthworkforceinformation,forecastingandperformancetrackingusingtheHRISinformationplatformandWSINmethodology.

Medical products

TheMinistryofHealthhasestablishedapharmacydeskinchargeofpolicyformulationand responsible for heath product regulations. The Rwanda Food and MedicinesAuthoritywillbeestablishedasanautonomousagencytoseparateimplementationandregulationfunctions.

Procurement, storage and distribution of health commodities are key pillars of aneffectivehealth-caresystem.InRwanda,procurementfunctionsaremainlyfulfilledbytheCentralMedicalStore(currentlyMPPD),referralhospitals,BUFMAR,privatepharmacywholesalers,districtandprivatepharmacies.Districtandhospitalpharmacieshavebeencreated and strengthenedproviding a systemof activedistributionofmedicines andcommodities.

2.6. Contributions to the global health agendaRwandahasmademajorcontributionstotheglobalhealthdevelopmentagenda.Mostofthesecontributionshavebeeninknowledgemanagementandresearch,innovativeapproaches,andfinancialandtechnicalsupport.

Knowledge management and research

Health research inRwanda isbenefiting fromstrongpoliticalcommitmentwithin theMoHandinthecountryatlarge.Thereareseveralhigh-levelresearchinstitutionswithwideinternationalnetworksincludingtheInstituteofHIV/AIDSDiseasePreventionandControl(IHDPC)andtheDivisionofMedicalResearchbothpartoftheRwandaBiomedicalCentre;theSchoolofPublicHealth(UniversityofRwanda);andtwoacademic(universityteaching)hospitals.

Important health research has focused on disease control and prevention, socialdeterminantsofhealth inRwandaandhealthsystems.Specificstudieshave includedmonitoringandevaluationofsystemstrengtheningforHIV,tuberculosisandmalaria;TBprevalence;implementationofindoorresidualsprayingformalaria;yellowfeverrisks;rotavirusvaccine(incollaborationwithCDC,Atlanta);NCDs(alsowithCDC);measles/



rubellaandcongenitalrubellasyndromecampaigns; immunization;andtheeconomicburden of diarrhoea among children aged under five years (in collaboration withPATH).ThehealthsectorwasexaminedthroughtheEDPRSIself-assessmentusingthesectorwideapproach (SWAp)and integrated intoHSSP III. FunctionalityofCHWswasassessed(incollaborationwithNewVision)inninedistricts.

Innovative approaches

Rwandahasintroducedavarietyofinnovativeprogrammesandinitiativesinthehealthsector(Table1).

Table 1: Health sector programmes and initiatives, Rwanda

Programme or initiative

Description (purpose, expected outcome, beneficiaries)

Impact

Community health Provision of health services at community level in order to improve child and maternal health and health promotion; 3 CHWs at village level (includes 1 male and 1 female CHW for child case management, 1 female CHW for maternal and child health support)

Improvement of the health status of the population

Community‑based health insurance

Ensure that the entire population accesses health services without financial barriers in a more equitable, progressive and sustainable manner with strong subsidization for the poor and vulnerable groups

Serve the population that is not in other health insurance schemes (90%)

Performance‑based financing

Financing of health services based on performance; incentive to health care providers; regular assessment using quantitative and qualitative indicators

Public health facilities

Rapid SMS Mobile phones distributed to CHWs for communication with health care facilities in case of emergency and to submit community health data

45 000 CHWs

Child growth monitoring

Regular follow‑up of nutrition status of children aged under five years and identification of malnutrition cases for early treatment

All U5 children

Community‑based FP services

Increased use of contraception by facilitating access to FP commodities; CHWs trained on the provision of FP methods at community level

CHWs, women

MoU with external specialized services to treat patients

Heart surgery, treatment of genital fistula, cleft palates, neuro‑spinal surgery, and other diseases needing specialized health care

Patients in need of specialized services that are not available locally

Maternal and child death audits

Audit hospitals to identify the real causes of maternal death and take preventive measures

All hospitals

Patient’s Charter of Rights and Responsibilities and customer care

Improve satisfaction of patients and other clients seeking services in health‑care settings

All the population

Toll‑free hotlines; use of social media

Improve satisfaction of patients and other clients seeking services in health‑care settings

All the population



Financial and technical support to other countries

In Rwanda, there is currently a strong political and institutional orientation towardsintegrationandinformationsharingwithothercountriesforhealthdevelopment.Thecountryhasorganizedandhostedvariousconferencesandsummitsinpartnershipwithotherstakeholders.

Collaborativemeetingshave included the fourth EastAfricanCommunityHealth andScientificConference, International Trade Fair andHealth Exhibitionwith a themeofregional health priorities and opportunities; a regional conference on social healthprotection in the EAC; Integrated Child and Adolescent HealthWeek duringwhich anewcombinedmeasles/rubellavaccinewasintroducedmakingRwandathefirstAfricancountrytorolloutthisvaccine;theInternationalConferenceonMentalHealthwiththethemeofmassviolence,mentalrehabilitationandsocialties;theeighthannualNationalPaediatricConferenceonchildreninfectedandaffectedbyHIVandAIDSthethemeofstrengtheningcommunityownershipforequitable,effectiveandsustainableresponsetoHIVamongchildreninRwanda;the19thConferenceoftheInternationalUnionAgainstTBandLungDiseases,AfricaRegion;NCDSynergiesNetworkinauguralmeeting.

Inaddition,thereistheCentreofExcellenceintheSchoolofPublicHealthofRwandawhichisfacilitatingandcoordinatingmanystudytoursfromdifferentcountriestolearnfromRwanda.Ofspecialinterestarethebestpracticesinhealthfinancing.

2.7. SummaryThere is a strong linkbetweenhealthanddevelopment; someachievementsoutsidethe health sector had a positive impact on health. Rwanda has made remarkablesocioeconomicprogressduringthepastdecadewithrealGDPgrowthaveraging8.2%annually.Thecountryisontracktoachieveuniversalaccesstoprimaryschooleducationby2015.

Within the health sector, Rwanda has recorded significant improvements in healthoutcomes over the last decade with both infant mortality and maternal mortalitydecreasing.There isa remarkabledecrease inprevalenceofwasting inchildrenagedunderfiveyears.TheHIV/AIDSnationalprevalencewas3%inpeoplebetweenages15and49;97%ofhealthfacilitiesofferARTandPMTCTservicesacrossthecountry,andthenumberofpatientsonARTincreaseddrasticallyfrom2005to2014.ThecurrentTBprevalenceis114/100000people,andtheTBmortalityratehasbeenreducedby78%.ARTinitiationamongTBandHIVco-infectedpatientshasincreasedto91%.Themalariamortalityratehasalsodecreasedby85%overthepasttenyears.



Varioushealth challenges remainhowever andone is to increase the accessibility offamily planning services as the demands also increase. There remains a shortage ofskilled health professionals countrywide, and there is growing need for specialistdoctors.Anotherchallengeisfinancialsustainabilityofhealthfacilitiesandservices.Thecountryalsoneedstodevelopthecoordinationandcapacitytorespondtodisastersandepidemics.

Variousopportunitieshaveprevailedinthehealthsector.Rwandabenefitsfromstrongpoliticalwillandgoodleadershipwhichiscitizen-centredandencouragesinclusivenessandmultisectorparticipation.Performancecontractssupportandensureaccountabilityateachdecision-makinglevelthroughperformancecontracts.Finally,thechiefexecutivehaspromotedhome-grownsolutionstonationalproblemsbasedonlocalcultureandhistory.



3. Development cooperation and partnerships

3.1. Aid environmentTheGovernmentofRwanda(GoR)iscommittedtopursuingtheParisDeclarationonaideffectiveness,harmonizationandalignmentandtheAccraAgenda.CleargovernmentobjectivesarestatedintheAidPolicyandsupportingstrategies.

Mutualaccountability is institutionalized,anddevelopmentpartner(DP)performanceismeasuredregularlyaccordingtotheagreedindicatorsintheCommonPerformanceAssessmentFrameworkforgeneralbudgetsupport(GBS)andsectorbudgetsupport(SBS)partners.ThehealthsectorholdsregularjointsectorreviewmeetingsatbothnationalanddistrictlevelsbetweengovernmentandDPs.TheMinistryofHealthcoordinatesthenationalhealthreviewmeetingwhileatthedistrictleveltheJointDevelopmentActionForumiscoordinatedbythedistrictauthorities.

The development partners engaged in the health sector are broadly aligned to theHSSPIIIpriorities.HSSPIIIisajointlyagreedplanbetweentheGoR/MoHandmostDPs.Thisarrangementisdesignedtofacilitatein-depthdialoguebetweentheGoRandDPsat sector and subsector levelwith a view to ensuring joint planning, coordinationofsupport,monitoring,evaluationandownership.

3.2. Stakeholder analysisThe newDivision of Labour (DoL arrangements have also resulted in some agenciessuch as DFID, GIZ and JICA moving to other sectors. Under current arrangements,theGoRestablishedadivisionof laborarrangement for coordinationofdevelopmentactivitiesandpartnershipinallsectorsincludinghealth.TheDoLclearlydefinesrolesandresponsibilitiesandensuresthatdevelopmentactivities including investmentactivitiesarealignedtotheParisDeclarationandharmonizedwithnationalrulesandregulations.TheDoLhasresultedinadynamicscenariowhereDPsinthehealthsectorareshiftingfrom a vertical to a mainstream approach, aligning with government priorities andincreasingtheuseofexistingproceduresandaccountabilitymechanisms.

ThehealthexpenditurehasgrownfromaboutUS$10percapitain1998toalmostUS$14percapitain2010.Mostofthisgrowthisduetoanincreaseinfundingfromdonorswhich


represented61%oftotalhealthexpenditurein2010(NHA,2010).Financialcontributionfrompartnerstothehealthsectorisimportant.In2011-2012,DPscontributedalargeproportion of the health sector budget; for example, PEPFAR, the Global Fund andPresidentialMalaria Initiative contributed 59% of the total health expenditure (MoH,2012b).

Development partners also play an active role in supporting the identification andresponse to health sector challenges. They actively participate in technical workinggroups and also in the Joint Health Sector Review where solutions to problems areidentifiedanddiscussed.Toensuresustainabilityofsupport, thegovernmentandDPssignedamemorandumofunderstandingoutliningthenatureandscopeofDPsupport.

3.3. Coordination and aid effectivenessDevelopment activities in the country are coordinated by the Development PartnersCoordination Group (DPCG) which is the highest-level coordination body in thecountry.Eachgovernmentlineministryanddonoragencyinthecountryhasaprimaryand secondary representative to the DPCG to ensure adequate representation andinstitutionalmemory.Theprimaryrepresentativesareusuallythein-countryheadsofdonororganizationsorthepermanentsecretariesintherespectiveministries.

TheGovernmenthasundertakenanumberofreformsandotherinitiativesincludingtheDivisionofLabour2011tofacilitatebetterimplementationoftheAidPolicy.Theoverallshift is toencourageDPconfidence,useexistingfinancialandaccountabilitysystems,anddecreasetransactioncosts.

The on-going changes in the SWAP and aid coordination architecture have resultedinDPssigningMoUs in their respectivesectors.Thisarrangementhasalso facilitateddecreased fragmentation among partners in the country. In addition, to minimizeduplication, decrease transaction cost and improve greater government ownership,thegovernmenthasestablishedaSingleProjectImplementationUnitineachministry(AbbottandRwirahira,2012).

WHOco-chairstheCountryCoordinatingMechanism(CCM)fortheGlobalFundtofightAIDS,TuberculosisandMalariaandisalsoactiveinthevariousDPCGmechanismsinthesector.

Development cooperation and partnerships


3.4. UN Reform status and CCA/UNDAP processTheUnitedNations in Rwanda is committed to the vision of Delivering as One. TheUN Rwanda Country Team has developed in partnership with GoR the Rwanda UNDevelopment Assistance Plan (UNDAP) 2013-2018 drawing on lessons from the pastcooperationframework(UNDAF).

TheUNDAP2013-2018isstrategicandresultsorientedandreflectstheUN’sincreasedfocusondeliveringupstreamtechnicalsupportinnationalplanningandimplementationprocesses, capacity development, high quality policy advice and technical expertisebased on best practices. UNDAP has captured comprehensive health priorities forsupportbytheUNwhichisalignedtodesiredhealthoutcomesforthecountry.UNDAPidentifiedpriorityareasincludinghealth.WithinUNDAP,thehealthsectorprioritiesarereflected intheflagshipprogrammedocumentfor2013-2018entitled“Strengtheninghealthandpopulationsystemswithimprovedgovernance,analysisandmonitoringofresults”anddevelopedinpartnershipwiththeMinistryofHealth.ActivitiesoutlinedinthedocumentarecoordinatedthroughtheDevelopmentResultsGroup(DRG)workinggroups.

TheUNDAP2013-2018programmeresultareasandoutcomesarehighlightedinFigure3.

Figure 3: UNDAP 2013-2018 Programme Result Areas and Outcomes

Result Area 1:Inclusive Economic

Transformation

Result Area 2:Accountable Governance

Result Area 3:Human Development

Result Area 3B:Humanitarian Response

and Disaster Management

Outcome3B.1:Reducednegativeimpact

andrecoveryfromhumanitariancrises

Outcome3.1:Accesstoquality,EHD,nutrition,educationand

protecttion

Outcome2.1:Accoutnabilityandcitizen

participation

Outcome1.1:Pro-poorgrowthand

economictransformation

Outcome1.3:Sustainablemanagement

oftheenvironment

Outcome1.4:Sustainableurbanization

Outcome1.2:Adiversifiedeconomicbase

Outcome2.2:Humanrights,justiceand

genderequality

Outcome3.2:Accesstoequitable

andqualitypromotive,preventive,curativeandrehabilitativehealth

services

Outcome3.3:Reducedexposureto

livelihoodrisk,inequalitiesandextremepoverty



MostofthestrategicprioritiesinthethirdCCSarewellalignedtoResultArea3andResultArea3BasdemonstratedinSection5.4.WHOisplayinganactiveroleinimplementationinpartnershipwithotherUNagencies.WHOcoordinateshealth sector interventionswithinUNDAPonbehalfofotherUNagenciesinvolvedinthesector.

3.5. SummaryKey health achievements

Keyhealthachievementshavebeenmadeinthecountry.ThereisanagreedjointplanbetweentheGoRMoHanddevelopmentpartners.ASWAPimplementationmanualandaroadmapweredevelopedandendorsed inOctober2010,andbiennial jointhealthsectorreviewshavebeenheld.TheDevelopmentPartnersCoordinationGroupasajointmechanismbetweentheGoRandDPsensuresaidcoordination.Thedivisionoflabourarrangementisoperational.

Opportunities

Variousopportunitiesprevail inthehealthsector.Universalhealthcoveragehasbeenadopted.Theimplementationofseveralhealthreformsisongoing.Mutualaccountabilityis institutionalized. DP performance is measured regularly according to the agreedindicatorsintheCommonPerformanceAssessmentFramework.TheGoRiscommittedto addressing theunfinishedMDGagenda and to implementing thepostMDG2015developmentagenda.Inaddition,highlevelpoliticalcommitment,enablingpolicyandinstitutionalmechanismsarepresenttoaddressthesocialdeterminantsofhealth.WHOhasongoingstrategicpartnershipswithkeystakeholdersinhealthandothersectors.

Challenges

Variouschallengespersist.Donorcontributionstothehealthsectorcontinuetodeclinewhilegovernmentcontributionsarestilllow.Comprehensiveanalysisofsomechallengesneeds to be strengthened. Use of health information is limited, and information onhealth-relatedcostsandexpendituresisnotfullycaptured.



4. Review of WHO cooperation over the past CCS cycle

4.1. Review processThisreviewprocessisbasedonfindings,lessonslearntandemergingissuestoguidethedevelopmentofthestrategicagendafor2014-2018.ThereviewofWHOCCScycle2009-2013wasundertakenthroughaconsultativeprocessinvolvingtheMinistryofHealth,developmentpartners,NGOs,UNagenciesandWHO.ThereviewprocessusedtheWHOCountryCooperationStrategiesGuide2010,key informant interviews,questionnairesandstakeholderconsultationsessions.RelevantdocumentswerereviewedandseniorMoHofficialswereconsulted.Thereviewprocessincludedanalysisoftrendsrevealedin the various RwandaDemographic andHealth Surveys (2005 and 2010) and othernationaldocuments.

4.2. Framework for analysing partner perceptions

WHO contribution to enhancing national ownership

WHOworksinpartnershipwiththegovernmenttoensurebetterplanning,implementationandmonitoringofprogrammes including strengtheningexisting coordination suchashealthsectorworkinggroupsandtheCountryCoordinationMechanism(CCM).WHOprovidestechnicalexpertiseandworkscloselywiththeMinistryofHealthtodevelopandreviewhealthpolicies,strategicplansandnationalguidelinessuchasthedevelopmentoftheHSSPIIIandothersubsectorpoliciesandstrategies.TheWHOalsosupportstheMoHincapacity-buildinginvariousareasofneed.

WHO alignment with national health priorities

WHOiswellalignedtonationalhealthprioritiesandnationalhealthtargetsasset inEDPRSII,Vision2020andHSSPIII.WHOhasledeffortstodevelopmostofthestrategiesincoordinationwiththevariousdepartmentsoftheMoHandotherDPs.TheCCS2009-2013wasimplementedthroughbiennialplanswhichwerepreparedinconsultationwiththeMoHand alignedwith national priorities. Technical experts in theWHOCountryOfficeplayedanactiveroleinthepreparationofMoHannualandstrategicplans.


Harmonization of WHO and national procedures and processes

WHOprogrammesharmonizewellwithGovernmentofRwandarulesandproceduresto enhance aid effectiveness. The GoR is committed to pursue the Paris Declarationonaideffectivenessonownership,harmonizationandalignment, results andmutualaccountability as well as the Accra Agenda for Action on aid effectiveness. Mutualaccountabilityisinstitutionalized,andDPperformanceismeasuredregularlyaccordingto the agreed indicators in the Common Performance Assessment Framework forgeneral budget support (GBS) and sector budget support (SBS). In addition, WHOsystemsalignwiththenationalprocurementsystem. Inthemid-termreviewofHSSPII,theOneUNapproachwasrecognizedasadvancedinharmonizationstreamliningUNagency procedures, reducing specific procurement requirements and thus becomingmorealignedcomparedtootherDPs.

WHO and the UN Country Team

WHOisamemberoftheUNCTandisabrokerforhealthdevelopmentamongallpartnersandacrosssectors.WHOcollaboratedeffectivelywithotherUNCTpartnerstoidentifyandimplementhealthsectorprioritiesincludingthoseoutlinedinUNDAP2013-2018.TheprioritiesimplementedarewithinthecorefunctionsandprioritiesofWHO.WHOalsoworkswithDPstostrengthentheirsupporttoidentifiedhealthsectorpriorities.

WHO’s comparative advantage

WHOfocusesonconsolidatingitsareasofcomparativeadvantageincludingprovisionofnormsandstandards,guidelines,policydevelopment,researchandevidencegeneration;the Organization has also supported programme intervention areas such as healthemergencypreparednessandotherservicedeliveryprioritiesoutlinedinHSSPIII.WHOhasplayedakeyroleinsupportingimportantgovernmenthealthprogrammesincludingGFATM and immunization activities. It has also supported planning, implementation,programmemonitoringandevaluation,andadvocacyforresourcemobilization.

4.3. Internal reviewThe internal review and reflection exercise was undertaken to assess the degree ofimplementationandinternalcapacitytoimplementtheCCS.Theexercisedemonstratedthat implementationoftheCCSsupportedstrengtheningoftheWHOCountryOffice.Intheperiodof implementationof theCCS, theCOgrewthroughtherecruitmentofadditionalnationalandinternationalstaffmemberstoaugmentcapacity.Aspartofon-goingcapacity-building,WHOCountryOfficestaffmembersbenefitedfromtrainingin

Review of WHO cooperation over the past CCS cycle


importanthealthdevelopmentareassuchasadvocacy,communicationskillsanddatamanagement.TheCOalsofacilitatedseveralmissionsfromtheWHORegionalOfficeandHeadquarterstosupportnationalauthorities.

Key findings

Key achievements include reduction in maternal and child mortality arising fromsustained gains, increased immunization and assisted deliveries. In the control ofcommunicablediseases,thecountryrecordedsuccessesintheburdenofmalaria;hightreatmentsuccessrateforTB;andincreasedcoverageofVCT,ARTandPMTCT.InNCDs,implementationofactivitiesisongoingincludingthenationalSTEPSsurvey.Inaddition,the country recorded improved access to health services. Successful multisectoralpreventive interventions include health promotion with an emphasis on nutrition,environment and the social determinants of health. Several improvements in healthsystemperformanceresultedinthecompletionofthehealthsectorstrategicplanandreviewofotherimportantplans.

Emerging issues

DuringtheperiodcoveredbytheCCS2009-2013,importantissuesandchangesinthehealth sector emerged with implications for future programming. These include theneedtoenhanceuniversalhealthcoverage;promotesustainabilityespeciallyofhealthsectorfunding;prevent,manageandcontrolNCDsandchronicmalnutritioninchildren;harmonizeinformationgathering,dataanalysisanddatause;andincreaseinvolvementof the private sector.Other issues include increasing community participation in themanagementofhealthservices(governance);integratingdecentralizedhealthservices;integrating IT platforms for information gathering as well as data analysis, display,dissemination and use; and strengthening knowledge management and research,includingeHealth.

Toensurealignmentandharmonizationof rulesandprocedures, theGovernmentofRwandadevelopedkeystrategicdocumentsincludingEDPRSIIandHSSPIIIthatclearlyoutlinestrategiesandprioritiestoachievehealthgoals.UNagencies inRwandahavealsotransitionedintheimplementationperiodfromverticalinstitutionalprogramingtoamainstreamedcomprehensivestrategicapproach.Inaddition,eachoftheseprocessesiswellalignedwiththethreeguidingprinciplesofthe2014healthsectorpolicy:people-centredcare,integratedservicesandsustainability.

Toenhanceprogrammeeffectivenessandcoordination,theGoRadoptedtheDivisionofLabour(DoL)2013policy;atthesametime,theGlobalFundintroducedtheresults-



based fundingmodel.Both shifts in approachhave resulted innecessary changesbydevelopmentagencies.ThenewDoLarrangementshavealsoresultedinsomeagenciessuch asDFID,GIZ, JICAmoving to other sectors. Some agencies havemodified theirtechnical support focus using a comprehensive assistance approach including SBS,basketfunding,theCapacityDevelopmentPooledFundandinstitutionalstrengtheningprojectsupport.

Inordertoreducethecountry’sdependencyonforeignaid(40%ofthecurrentbudget),the GoR mobilized domestic resources and has successfully increased the domesticrevenues toGDP ratio in the past several years. However, the level is still far belowthe regional average. To address the unpredictability of external support and overallsustainability, theGoRhas introducedanumberofpositive initiatives. These includeincreasingthedomesticrevenuetoGDPratio;increasingtheuseoflocalrevenueforhealthtocomplementongoingexternalinvestments;improvingefficiencyandeffectivenessofinterventions includingmanagerialreforms;andpromotingtheprinciplesofvalueformoneyandaccountability.Moreover,theGoRhastakenadditionalactionstopromotefavourablepolicyincentivestoenhancelocalandexternalprivateinvestmentinhealthincludingPublicPrivateCommunityPartnership.

In themeantime,while thecountryhasachievedpositiveprogress in theattainmentofmostoftheMDGtargets,someunfinishedMDGagendaitemsremainandrequireaction.Rwandahasplayedaleadershiproleinarticulatingconcreteactionstoimplementthepost2015developmentagenda.Meanwhile,thecountryisalsoacceleratingactionsto implement theRwandaSocialProtectionStrategy (2011)andachievementofUHCtargetsincludingoutlinedprioritytargetsinthe12thWHOGeneralProgrammeofWork20142019(approvedbytheSixty-sixthWorldHealthAssembly).

Overall,thereviewacknowledgedthatWHOachievedusefulprogresswithinthecontextofstated

objectives including the progress achieved in the areas highlighted above. However,somehealthsystemchallengespersist.

Theachievement recorded in reductionof theburdenofcommunicablediseaseshasincreased awareness of the urgent need to address challenges associated with thegrowingburdenofNCDs.There isaneedtotakeactiontoaddressknownchallengesassociated with the social determinants of health including the vulnerabilities ofcommunitiestoclimatechange,epidemicsanddisasters.



4.4. SummaryTheWHOCountryCooperationStrategy2014-2018inpartnershipwiththeGovernmentof Rwanda is designed to be implemented around the following five key strategicpriorities:

a) Support health system strengthening towards health service integrationanduniversalhealthcoverage;

b) Contributetothereductionofmorbidityandmortalityfrommajordiseasesandthuscontributetotheachievementofthehealth-relatedMillenniumDevelopmentGoals;

c) Contributetothereductionofmaternal,newbornandchildmorbidityandmortality;

d) Promotehealth by addressing the social determinants of health, healthandenvironment,nutritionandfoodsafety;

e) Strengthen disaster risk management and epidemic emergencypreparedness and response; and implementation of the InternationalHealthRegulations.

Theoutlinedstrategicprioritiesareexpectedtogenerateclearactionstoachievehealthgoals and objectives including alignment with three guiding principles of the 2014Rwandahealthsectorpolicy:people-centredcare,integratedservicesandsustainability.

TheprioritizationofstrategiesalsofactoredexistingopportunitiesinthehealthsectorincludingtheDivisionofLabour(DoL)2011amongdevelopmentpartnersandexistingHSSPpriorities;theUNDAPplan2013-2018andongoingeffortsbyGoRtoaddressSDHandsocialprotection.Thedocumentbuildson important lessons learnt, isalignedtothe impressiveachievementsof theGoRsecondEconomicDevelopmentandPovertyReduction Strategy (EDPRS II) and considers objectives of the WHO 12th GeneralProgrammeofWork2014-2019.



5. Strategic agenda for WHO cooperation

The formulation of the strategic agenda forWHO cooperation for the period 2014-2018benefitedfromaninteractiveprocessofdialoguewithkeystakeholdersincludinggovernment,civilsociety,developmentpartnersandUNagencies.Theinteractionwithstakeholdersgeneratedidentificationofimportanthealthanddevelopmentchallengesin the health sector including sustainability of investment; constraints in scaling upessentialservicesforthepopulation;andcomplementaritiesandalignmentoftheCCSandHSSP.

To address some identified challenges, several opportunities for developingnational capacities including opportunities to strengthen workforce managerial andperformance capacity were considered especially data collection, analysis and use.Giventheexperienceandachievementsrecorded,attentionwillbegiventoprevention,managementandcontrolofNCDsandchronicchildhoodmalnutrition;healthsystemstrengtheningtowardshealthservicesintegration;andachievementofuniversalhealthcoverage.

Overall,on-goingactivitiesinthefollowingWHOleadershippriorities2014-2019willbeconsolidated:

a) Advancinguniversalhealthcoverage:enablingcountriestosustainorexpandaccess to essential health services and financial protection, and promotinguniversalhealthcoverageasaunifyingconceptinglobalhealth;

b) Addressing unfinished and future challenges of health-related MDGs:accelerating the achievement of the current health-related goals up to andbeyond2015includingtheeradicationofpolioandselectedneglectedtropicaldiseases;

c) Addressing the challenges of NCDs, mental health, violence, injuries anddisabilities;

d) ImplementingtheprovisionsoftheInternationalHealthRegulations:ensuringthat all countries can meet the capacity requirements specified in theInternational Health Regulations (2005) and support implementation of theDisasterRiskManagementStrategyforthehealthsectorintheAfricanRegion;


e) Increasing access to essential, high-quality and affordablemedical products(medicines,vaccines,diagnosticsandotherhealthtechnologies);

f) Addressingthesocial,economicandenvironmentaldeterminantsofhealthasameansofreducinghealthinequitieswithinandbetweencountries.

5.1. Strategic agenda for Government of Rwanda and WHO cooperation

TheRwandaCCSidentifiesfivestrategicpriorities,themainfocusareasandthestrategicapproachesforimplementation.Whilethescopeofoutlinedprioritiesisbroad,theWCOisverycognizantofcurrentglobalresourcescarcity;hence,activitiestobeimplementedwillbenefitfromfurtherrealisticassessmentgiventheprevailingresourcesituation.

5.2. Rwanda CCS strategic prioritiesa) Support health system strengthening towards health service integration

anduniversalhealthcoverage;

b) Contribute to the reduction of morbidity and mortality from majorcommunicable and noncommunicable diseases and conditions towardsconsolidationofhealth-relatedMDGgainsandachievementsofpost2015developmentgoals;

c) Contributetothereductionofmaternal,newbornandchildmorbidityandmortality;

d) Promotehealth by addressing the social determinants of health, healthandenvironment,nutritionandfoodsafety;

e) Strengthen disaster risk management and epidemic emergencypreparedness and response; and implementation of the InternationalHealthRegulations.

Strategic agenda for WHO cooperation


Main focus 1.1: Support the Ministry of Health to strengthen capacity for health system governance and stewardship

a) Providetechnicalsupporttostrengthencapacitytodevelopandimplementpoliciesaswellaslegislative,regulatoryandfinancialframeworks through generation and use of evidence, normsandstandardsforarobustplanning,monitoringandevaluationcycle;

b) Provide technical support to strengthen capacityofmanagersof health services and programmes at all levels (includingprivatesector)foreffectivemanagementanddeliveryofhealthservices;

c) Provide technical support to improve coordination andeffectiveness of the health sector in respect of sectorwideapproachprinciples(centralanddecentralized);

d) Providesupportforjointmonitoringandevaluationofprogresstowards universal health coverage including joint sectorreviews.

Main focus 1.2: Support the Ministry of Health to improve service delivery

a) Provide technical support to develop guidelines, tools andsupportforimprovedpatientsafetyandqualityofservicesforpatientempowerment;

b) Provide technical support to review and develop norms,standardsandprotocolsensuringhealth-carequalityassurancewith better harmonization of existing quality assurancetools (integrated supervision, PBF quality assessment andaccreditation).

Strategic priority 1: Support health system strengthening towards health service integration and universal health coverage



Main focus 1.3: Strengthen country capacity to develop strategies and mechanisms to improve production and management of human resources for health

a) Provide technical support to plan and implement strategiesthatareinlinewiththeglobalstrategyonHRHandtheGlobalCode of Practice on the International Recruitment of HealthPersonnel;

b) Promoteaccreditationoftrainingprogrammesandinstitutionsaccordingtointernationalstandards;

c) Emphasize capacity-building in specialized skills inhealth-caretechnologymanagementincludingbiomedicalengineeringandhospitalinfrastructureengineering;

d) Providetechnicalguidancetostrengthenlegislationandpolicyto promote the development, retention and sustainability ofa sufficiently skilled health workforce as well as implementguidelines for the transformationand scalingupof educationandaccreditationofhealthpersonnel.

Main focus 1.4: Strengthen country capacity to develop and implement a health financing system which ensures that quality essential health services are accessible to the whole population in an equitable, efficient, and sustainable manner

a) Identify needs and provide support to strengthen countrycapacity in developing and implementing legislative andregulatoryframeworks;

b) Providetechnicalsupporttopromote,developandstrengthenasustainablehealthfinancingsystemthatadvancesthegoalofuniversalhealthcoverage;

c) Providetechnicalsupporttoimproveefficiencyintheallocationand use of health resources and coverage of high impactinterventions;

d) Provide technical support to increase internal resourcemobilizationforsustainablefundingofthehealthsector;



e) Provide technical support to improve coordination andeffectivenessofexternalassistanceandnational resources forthehealthsector.

Main focus area 1.5: Promote improved access to health products and health-care technologies based on primary health care

a) Provide technical support to revise and implement nationalpoliciesforthepricing,procurementandmanagementofhealthproductsandtechnologies;

b) Strengthen capacity for regular, evidence-based updating ofbasicdocumentstopromoterationaluseofhealthproductsandtechnologies including the national list of essentialmedicinesandtherapeuticsprotocols;

c) Providetechnicalsupportfortheregulation,qualityassuranceandmanagementofessentialhealthproductsandtechnologies.

Main focus area 1.6: Promote health system information and evidence sharing, monitoring of trends, data generation and analysis of health priorities, eHealth, health research and knowledge management

a) Support the development and strengthening of data sourcesincludingcivilregistrationandvitalstatistics;

b) Support theavailabilityanduseof routinehealth informationsystems (HIS) to inform implementation policies as well asinitiateandpromoteresearchbasedontheHIS;

c) Support development and use of knowledge managementpolicies, tools, networks, assets and resources and promotesystematicuseofevidenceintheformulationofnationalpoliciesanddecision-making;

d) Providetechnicalsupporttostrengthenhealthsystemsresearch,monitoringandevaluation;andsupport implementationofaneHealthstrategy;

e) Provide technical support to keep national authorities andstakeholders informedaboutemergingknowledge inorder tostrengthendeliveryamongpotentialusers;



f) Build thecapacityofhealthprofessionalsandMoHpersonneltosynthesizeanddisseminatelessonslearntandgoodpracticesfrom implementation of innovative policy initiatives, researchfindingsandpilotprogrammes.

Strategicpriority2:

Main focus 2.1: Support the health sector to prevent and control HIV and AIDS, malaria, tuberculosis, neglected tropical diseases and other communicable diseases

a) Provide technical support to maintain adequate nationalresponse to HIV towards universal access to HIV and AIDSprevention,careandtreatment;

b) Provide technical support to accelerate and scale up cost-effectivemalariainterventionstowardsuniversalcoverageandattainmentofmalariapre-eliminationby2018;

c) Provide technical support to accelerate the implementationof Stop TB by expanding and enhancing implementation ofDOTSand strengthening capacityof theNationalTuberculosisProgramme;

d) Provide technical support to strengthen the capacity of NTDprogrammemanagerstodevelopandimplementanNTDbudgetmasterplan;

e) Provide support to enhance NTD monitoring and evaluation,surveillance,andoperationsresearchincludingthemappingoflymphaticfilariasisinthecountry;

f) Provide technical support to improve community access touptakeofEPI/VPDservicesthroughtheReachEveryChild(REC)approachandsupplementaryimmunizationactivities(SIAs)andtoreinforcethecapacityofVPDandAEFIsurveillanceatalllevels.

Strategic priority 2: Contribute to the reduction of morbidity and mortality from major communicable and noncommunicable diseases and conditions towards consolidation of health-related MDG gains and achievement of post 2015 development goals



Main focus 2.2: Support prevention and control of noncommunicable diseases

a) Provide technical support in the development andimplementationofprotocolsandguidelinesforNCDpreventionandcontrol;

b) Provide technical support to strengthen NCD surveillancesystems,monitoringandevaluation;

c) SupportresearchtowardsintegrationofNCDsinservicedelivery.

Main focus 3.1: Support Ministry of Health to improve access to sexual and reproductive health information and quality services with focus on the life cycle approach

a) Provide support for the development, review and update ofpolicyandstrategies,norms,standards,toolsandguidelinestoimprovethequalityofSRHandadolescent-friendlySRHservices;

b) ProvidesupporttoMoHforadvocacy,research,useofevidence,monitoringandevaluationforrelevantareaspertainingtoSRHissues.

Main focus 3.2: Strengthen national capacity to improve maternal and child health interventions including access to skilled attendance at deliveries and to scale up high impact child survival interventions

a) Provide support for strengthening partnerships, evidencegeneration, norms and standards, advocacy, resourcemobilizationandinnovationincludingensuringqualitychildandnewbornhealthservicesespeciallycommunity-basedintegratedservices;

b) Provide support to build capacity of health-careproviders forquality essential and emergency maternal and newborn careincludingECDandPMTCTthroughinterventionsthatreachfromhouseholdandcommunitylevelstotertiarylevel;

Strategic priority 3: Contribute to the reduction of maternal, newborn and child morbidity and mortality



c) Provide support for capacity-building on key child healthinterventions including Integrated Management of ChildhoodIllness, quality paediatric referral care and management ofsevereacutemalnutritionforhealth-careproviders,tutorsandprogrammemanagers;

d) Provide support tomove from amaternal death audit and anewbornandchilddeathaudittomaternal,newbornandchilddeath surveillance and responsewith focus on strengtheningresponse.

Main focus 3.3: Strengthen immunization systems including preventable disease surveillance and cold chain management, and support the introduction of new vaccines

a) Provide support to increase immunizationcoveragenationallyandreducethenumberofunvaccinatedchildrenbyextendingRECtopoorlyperformingzones;andtoimprovemonitoringbyproviding high quality data, increasing supportive supervisionandimprovinginternalandexternalreportingsystems;

b) Support the introductionof newvaccinesby encouraging thegovernment to increase co financing and provide technicalsupporttoresearchdiseaseburdens;

c) Provide support to develop policy and strategies for theprovisionofcoldchainmaintenance,monitoringandreporting;

d) Provide support for the implementation of immunization andsurveillance activities towards achieving global and regionalaccelerateddiseasecontrol targets(polioeradication,measleselimination, and maintaining maternal and newborn tetanuselimination) by developing clear SOPs for VPD surveillance,increasing capacity of laboratories and increasing communityinvolvementindetectionandreportingofVPD.

Main focus 3.4: Strengthen surveillance, prevention and management of malnutrition in mothers, infants and young children

a) Provide support to develop amultisectoral and decentralizedfood and nutrition policy as well as strategy and nationalstandardsaimedatreducingallformsofmalnutrition;



b) Providesupport to strengthennutritionsurveillancebasedonsocial clusters in existing systems and to conduct a nationalsurveydeterminingthecausesofstunting;

c) Provide support to build capacity at all levels to proactivelyprevent and manage malnutrition in mothers and childrenthrough improved counselling to families onmaternal, infantand young child nutrition; growth monitoring; and use ofinnovativeapproaches;

d) Provide support to build the capacity of health providers inoperationalresearchaimedatreducingmalnutrition.

Strategic priority 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety

Main focus 4.1: Promote health and the social determinants of health

a) Support implementation, monitoring and evaluation ofhealth promotion activities at decentralized level based onempowerment and full participation of communities in amultisectoralapproach;

b) PromotehealthylifestylesaddressingNCDriskfactorsincludingtobacco,alcoholand substanceabuse;physical inactivity;andmalnutrition;targetschoolagesandothervulnerablegroups.

Main focus 4.2: Promote a safer and healthier environment, improved nutrition and food safety

a) Provide technical support for improvingwater, sanitation andhygieneservices;

b) Provide technical support for multisectoral interventions andcollaborationinaddressingtheenvironmentaldeterminantstohuman health (air pollution, water pollution, climate change,chemicals)andecosystemintegrity;

c) Provide technical support to strengthen national anddecentralized systems for food safety inspection and riskanalysis;



d) Providetechnicalsupporttobuildcapacityonnutritionalcarefor prevention and management of NCDs; and contribute tothenationalfirst thousanddayscampaigntopreventstuntingthroughcapacity-buildingofhealth-careprovidersatall levelsonmaternal,infantandyoungchildnutrition.

Main focus 5.1: Support the Ministry of Health to strengthen the capacity for implementation of the Integrated Disease Surveillance and Response through IHRs and One Health strategy frameworks

a) Providetechnicalsupporttostrengthenandimplementaneffective,efficientnationaldiseasesurveillanceandresponsesystem;

b) Provide support to strengthen surveillance, prevention, earlydetection, rapid response and control of zoonoses in bothhumansandanimals;

c) Provide support to implement the International HealthRegulations;

d) Provide technical support tomonitor and evaluate standardsandqualitymeasuresforasurveillanceandresponsesystem;

e) Provide technical support to conduct operational research toinformpolicies,advocacyandbestpractices.

Main focus 5.2: Support Ministry of Health and MIDIMAR to develop and implement preparedness and response measures for disaster risk management, prevention and control epidemics, and other emergencies

a) Providetechnicalsupporttoassesscountryrisksandcapacitiesfor disaster risk management and develop a road map forstrengtheningcapacities;

b) Provide support to develop preparedness for the control ofdisaster,epidemicsandotheremergencies;

Strategic priority 5: Strengthen disaster and epidemic emergency preparedness and response as well as implementation of the International Health Regulations



c) Contribute to strengthen disaster preparedness for effectiveresponse that includes response planning, training andeducation programmes, early warning, pre-positioning ofessentialsupplies,andsimulationsbasedonallrisksprevalentinthecountry;

d) Provide support to assess the safety and preparedness ofhospitals and health facilities and to implement resilience-buildinginterventionsinhealthfacilitiesandcommunities;

e) Provide support and participate in response and recovery todisasters,epidemicsandotheremergenciesbasedonnationalstandardoperatingprocedures.

5.3. Validation of the CCS strategic agenda with the third Health Sector Strategic Plan

The CCS strategic priorities were derived from the challenges identified duringimplementationofHSSPII;reviewofWHOcooperationforthesecondCCS;andnational,regionalandglobalcommitmentsincludingthepost2015developmentagenda.TheCCSstrategicprioritiesarealsoalignedtothethirdHealthSectorStrategicPlan2012-2018prioritiesashighlightedinTable2.

Table 2: Alignment of Country Cooperation Strategy and Health Sector Strategic Plan III priorities

CCS strategic priorities

HSSP III Priorities1 2 3 4 5

Sustain the achievements in MCH and the fight against infectious diseases

Improve accessibility to health services (financial, geographical, community health)

Improve quality of health provision (quality assurance, training, medical equipment, supervision)

Reinforce institutional strengthening (especially toward district health services units)

Improve quantity and quality of HRH

•Support health system strengthening towards health service integration and universal health coverage

• • • • •

•

Contribute to the reduction of morbidity and mortality from major diseases and conditions and thus contribute to the achievement of health‑related MDGs

• • • •

Contribute to the reduction of maternal, newborn and child morbidity and mortalityPromote health by addressing the SDH, health and environment, nutrition and food safety

• • • • •

Promote better disaster risk management, epidemic and emergency preparedness and response, and implementation of IHRs

• • • •



5.4. Validation of the CCS strategic agenda with the Rwanda UN Development Assistance Plan

TheWHOCountry Cooperation Strategy 20142018 Rwanda is aligned to theUNDAP2013-2018which is the five-year programme for cooperation developed to enhancetheUNDeliveringasOne.UNDAPisfullyalignedtothegovernment’sEDPRSII;Vision2020;andregional,continentalandglobalcommitments.Morespecifically,theCCSIIIisalignedtoResultArea1oninclusiveeconomictransformation;ResultArea3onhumandevelopmentfocusingonholisticchild,youthandfamilydevelopment;andResultArea3Bonhumanitarianresponseanddisastermanagement.Priorities,areas,outcomesandoutputsarehighlightedinTable3.

Table 3: Alignment of CCS priorities and UNDAP outcomes and outputs

CCS strategic priorities UNDAP 2013-2018 result areas and outcomes

UNDAP 2013-2018 outputs

• CCS Strategic Priority 1: Support health system strengthening towards health service integration and universal health coverage

Result Area 1: Outcome 2: Diversified economic base allows Rwandans to tap into and benefit from expanded international, regional and local markets, and improved agriculture value‑chains

Output 1.2.2: Strengthened national regulatory frameworks for quality standards compliance

• CCS Strategic Priority 3: Contribute to the reduction of maternal, newborn and child morbidity and mortality

CCS Strategic Priority 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety

Result Area 3: Outcome 3.1: All Rwandan children, youth and families, especially the most vulnerable, access quality early childhood development, nutrition, education and protection

Output 3.1.1: Improved capacity of government institutions and communities to expand equitable access to quality integrated child and family servicesOutput 3.1.2: Strengthened, coordinated and monitored multisectoral strategies for sustained reduction of child and maternal malnutritionOutput 3.1.3: Strengthened capacities of the education sector to deliver inclusive quality basic education

• CCS Strategic Priority 1: Support health system strengthening towards health service integration and universal health coverage

CCS Strategic Priority 4: Contribute to the reduction of morbidity and mortality from major communicable and noncommunicable diseases and conditions towards consolidation of health‑related MDGs gains and achievements of post 2015 development goals

Result Area 3: Outcome 3.2: All people in Rwanda have improved and equitable access to and utilize high quality promotional, preventive, curative and rehabilitative health services

Output 3.2.1: Strengthened national capacities for health governance (policies, tools, plans, strategies, and standards), management, financing, human resources and management of information systemsOutput 3.2.2: Strengthened national and subnational capacity to provide quality integrated health servicesOutput 3.2.3: Strengthened community capacity to demand quality health services at all levelsOutput 3.2.4: Increased capacity of national service providers, civil society and private sector to accelerate development and implementation of evidence‑oriented integrated HIV/AIDS prevention, treatment, care and support programmes for key populations



CCS strategic priorities UNDAP 2013-2018 result areas and outcomes

UNDAP 2013-2018 outputs

• CCS Strategic Priority 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety

Result Area 3: Outcome 3.3: Vulnerable groups have reduced exposure to livelihood risk, inequalities and extreme poverty

Output 3.3.1: Strengthened capacity of national and subnational institutions in targeting, delivery, M&E of equitable and holistic social protection services to vulnerable groupsOutput 3.3.2: Strengthened national and sub national capacity to increase access to social security services especially for youth and womenOutput 3.3.4: Capacity of planners, decision‑makers, and key stakeholders strengthened to ensure a protective legal and policy environment for PLHIV and their families

• CCS Strategic Priority 5: Promote better disaster risk management and emergency, disaster and epidemic preparedness and response, and implement the International Health Regulations

Result Area 3: Outcome 3b.1: Reduced negative impact and improved recovery of affected populations due to humanitarian crises

Output 3B.1.1: Strengthened national capacities for emergency/humanitarian preparedness and response at all levelsOutput 3B.1.2: Improved protection and self‑reliance of refugees and other affected populations especially children, adolescents and women

• CCS Strategic Priority 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety

Result Area 1: Outcome 3: Rwanda has in place improved systems for: sustainable management of the environment, natural resources and renewable energy resources, energy access and security for environmental and climate change resilience in line with Rio+20 recommendations for sustainable development

Output 1.3.2: Strengthened capacity for sustainable environment, natural resources management, climate change mitigation and adaptationOutput 1.3.3: Strengthened capacity of national and local institutions to reduce disasters and risksOutput 1.3.5: Strengthened national capacities for planning and management of green villages

5.5. Validation of the CCS strategic agenda with the WHO 12th General Programme of Work

Table 4: Alignment of CCS priorities and main focus areas with the WHO 12th GPW categories, 2014-2019

CCS strategic priorities

12th WHO GPW categories 2014-2019

1: CD control

2: NCD control

3: Health in the life course

4: Health systems

5: Disaster preparedness and response

Strategic Priority 1: Support health system strengthening towards health service integration and universal health coverageStrategic Priority 2: Contribute to the reduction of morbidity and mortality from major communicable and noncommunicable diseases and conditions towards consolidation of health‑related MDG gains and achievements of post 2015 development goalsStrategic Priority 3: Contribute to the reduction of maternal, newborn and child morbidity and mortalityStrategic Priority 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safetyStrategic Priority 5: Promote better disaster risk management and emergency and epidemic preparedness and response and implementation of the International Health Regulations



6. Implementing the strategic agenda: implications for the Secretariat

6.1. The role and presence of WHOThe programming and operational environment in the country is changing withimplications for WHO on several fronts including how the Organization works andprovides technical support to governments andpartners. The approach and focusoftechnical support received from otherWHO levels also require rethinking and someadjustmentstobetteralignandrespondtothecountry’sneedsandrealities.

WHOwill need to consolidate its partnership and relationship-building strategies tobetterpositionitselfinthefast-evolving,largeanddiversepartnershipenvironmentinthecountry.HencethereisincreasedneedforfocusonareasofWHOclearcomparativeadvantage.Inaddition,concreteactionsareneededtoenhanceresourcemobilizationandensureavailabilityofskilledstaffthatwillcontributetobetterstrategicalignmentwithidentifiedCCSprioritiesusingtheacknowledgedprinciples.

ThedesiredroleofWHOintheimplementationofthestrategicagendaisbasedonthecountry’sneedsforsupportinimplementingnationalhealthsectorpriorities.WHOwillconsolidateitsroleasapolicyadviseronmajorhealthissues.

Normativefunctionswillbestrengthened,andeffortswillbemadetomobilizeadditionalfunding,particularlyforhealthsystemstrengthening,healthinformationsystems,health-carefinancing,implementationofIHRs,andaddressingvariousissuesthathavearisenduetostructuralchanges in thecountry.WHOleadershipandpartnership inmatterscriticaltohealthwillbeprovidedalongwithtechnicalsupporttherebycatalysingchangeandbuildingsustainable institutionalcapacity.Supportwillbeprovidedtostrengthenmonitoring and evaluation of health system performance, monitoring of the healthsituationandassessinghealthtrends.

The WHO Country Office needs to be equipped with adequate staff and financialresourcestoachievethestrategicobjectivesmentionedintheCCS.Currently,thestaffincludes three international members, namely theWHO Representative, a technical


officer inchargeofHISandatechnicalofficer inchargeofNCDsandnutrition.Thereareninenationalprofessionalofficersandanationaloperationsofficer.ForthenextCCSperiod,thefocuswillbeonstaffperformanceimprovementthroughcapacity-buildingaswellasenhancedperformancemanagementanddevelopment.

6.2. Using the Country Cooperation StrategyThenewCountryCooperationStrategywillguideWHOSecretariatworkwithRwandafrom2014to2018;inparticular,theCCSwillguidetheworkofWHOatalllevelsincludingpreparationofbiennialplans.TheWHORwandaCountryOfficewillwidelydisseminatetheCCSdocumenttothegovernmentandotherpartners.

TheCOwilluseCCSprioritiestoguidefutureworkplans.Inaddition,theCOwilluseCCScontenttocoordinatethehealthcomponentofUNDAPandotherpartnershipplatformswhilerecognizingpartners’contributions.TheCCSalsoservesasaguideforresourcemobilizationandadvocacy.

6.3. Monitoring and evaluationWHO will monitor CCS implementation using established procedures in partnershipwiththeGovernmentofRwandaandotherstakeholders.Effortswillbemadetoalignthe monitoring of priority programmes with the agreed-upon processes for theiroversight and accountability. These procedures will include a mid-term review andend-of-bienniumreviewofcollaborativeprogrammes.ThesewillalsocontributetotheWHObiennialprogrammebudgetperformanceassessment.Themid-termreviewmayconsider curtailing or phasing out someprogrammes,while identifying and initiatingactivities innewpriorityareas, inwhich caseWHOwill adjust collaborativeactivitiesaccordingly.WHOwillundertakeamid-termreviewof theCCScycle in2016-2017 inordertoensurethatcollaborativeworkplansandactivitiesareinlinewiththestrategicprioritiesandwithanyemergingneedsandlessonslearnt.

Implementing the strategic agenda: implications for the Secretariat


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Annexes

Annex 1. Organogram of WHO Rwanda Country Office

WHO Representative(P5: 132762)

Category 1:Communicable

diseases

Category 2:Non-Communicable

diseases

Technical Officer/NUT/NCD (P4:344370)

HIV/AIDS(NOC: 135026)

Tuberculosis(NOC: 302502)

Category 3:Promotinghealththrough

thelifecourse

Family Health Planning(NOC: 307036)

Health Information Promotion

(NOB: 134265)

Protection of Human Environment

(NOB: 135027)

Category 4:Healthsystems

Technical Officer-StrategicHealth Information &

Health systems Research (P4:344371)

Essential Drugs and Medicines (NOC: 135655)

Health Economics(NOC: 135029)

African Health Observatory - real time Strategic information

System (NOB: 361431)

Category 5:Preparedness,surveillance

andresponse

Extended Program of Immunization(NOC: 306964)

Disease Prevention and Control (NOC: 135028)

Category 6:CorporateServicesandenablingfunctions

NPO - Operations Officer (NOC: 342784)

Program, Budget and Finance Assistant

(GS7: 132763)

Logistics, Procurement and Travel Assistant

(GS6:344377)

HR Clerk (GS4: 344376)

Office Clerks (GS4: 135010)

Office Clerk (GS1: 135005)

Senior Driver (GS3: 136391)

NPO - ICT Focal Point (NOB: 135033)

WR Assistant (GS6:133521)

Program, Budget and Finance Clerk (GS5: 344378)

Logistics, Procurement and Travel Clerk (GS5: 135037)

Driver (GS2: 135008)




Annex 2. List of stakeholders contacted for CCS III development

Ministry of Health and line ministries Institutions UN agencies

Planning, M&E and HMIS Division World Relief WHO

Human Resources Belgian Technical Cooperation UNFPA

Mother and Child Health Rwanda Health Family Project UNICEF

Pharmacy Embassy of Belgium UN Dispensary

RBC/HIV Management Sciences for Health UN Women

RBC/TB/Other Respiratory Diseases National Paralympic Council UNAIDS

RBC/IHDPC World Vision WFP

RBC/Malaria and Other Parasitic Diseases Rwanda Association of Allied Health Professionals Council

RBC/NCD Rwanda Medical Association

Vaccine Preventable Diseases

RBC/Maintenance Medical Equipment

Community Health

RBC/HIV/Early Infant Dignosis

Decentralization and Integration

Human Resources for Health

Ministry of Disasters Management and Refugees

Ministry of Local Government

Ministry of Education

Ministry of Gender and Family Promotion

Ministry of Education

Ministry of Gender and Family Promotion

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