HEALTH SITUATION Rwanda has made remarkable socioeconomic progress in the past decade with real GDP growth averaging 8.2% annually. This has translated into improvements in the health situation. Major health reforms took place, including the health insurance improvement, which aims to guarantee access for all to health care; and experience from Rwanda has shown that it is possible to achieve universal health coverage in a country with 90% of its population in the informal sector. Life expectancy has doubled during the 20 years following the devastating 1994 genocide against the Tutsi, as a result of increase in the number of health facilities, improvement in immunization coverage, good access to safe drinking water, and improved housing. All targets related to the three health-MDGs were met, with a notable success in reduction of child mortality and considerable improvements in maternal health The HIV/AIDS national prevalence remains stable at 3% in people between ages 15 and 49; and the country has achieved one of the highest national ART coverage rates in sub-Saharan Africa, reaching 78.2% percent of those eligible for ART based on the new WHO ART guidelines. The current TB prevalence is 85/100 000 people, and the TB mortality rate has been reduced by 81%. Despite these achievements, several health challenges remain. These include malnutrition with 38% of under-five children still stunted. Malaria incidence is also on the rise, from 514,173 cases in 2012 to 1,967,402 cases in 2015. Increase in incidence of NCDs, as a result of the ageing of the population is another issue; along with the financial sustainability of health facilities and services. As consequence of the 1994 genocide against the Tutsi, the country also faces a large burden of mental disorders. Moreover, communicable diseases such as HIV/AIDS, acute respiratory infections, diarrhoeal diseases and tuberculosis account for 90% of complaints at health facilities. To cope with new emerging public health issues like Yellow and Rift Valley Fever, the Ministry of Health developed and implemented an outbreak preparedness and response plan. An electronic IDSR system, that is operational since 2013, was also established. HEALTH POLICIES AND SYSTEMS Based on the Rwandan Constitution, Articles 41 and 45, which states that all citizens have rights and duties relating to health; the country has committed to ensure universal access to affordable promotive, preventive, curative, and rehabilitative health services of the highest attainable quality. In this regard, Rwanda’s Ministry of Health has revised its National Health Policy, based on Vision 2020 and EDPRS II. The health system consists of three levels of service provision: central, intermediary and peripheral. The central level includes the central directorates and programmes of the Ministry of Health and the national referral hospitals. The largest health insurance programme is the Community-Based Health Insurance Scheme (CBHI), estimated to cover 81.4% of the population, and highly subsidized by the GoR. The GoR is committed to implement the post-MDG 2015 development agenda. In addition, high level political commitment, enabling policy and institutional mechanisms are present to address the social determinants of health. There is an agreed joint plan between the GoR, MoH and development partners. A SWAP implementation manual and a road map were developed and endorsed in October 2010, and biennial joint health sector reviews have been held. The Development Partners Coordination Group as a joint mechanism between the GoR and DPs ensures aid coordination and effectiveness. The division of labour arrangement is operational. WHO has ongoing strategic partnerships with key stakeholders in health and other sectors and it will support the health development agenda of the GoR. Under the umbrella of the One UN, WHO is supporting the MOH to develop and implement an SDGs domestication strategy and plan. The organization will engage across all sectors to ensure mainstreaming of health into the other SDGs. The overall policy objective is to strengthen policies, resources and management mechanisms of health support systems to ensure optimal performance of the health programmes so as to achieve the SDGs. Various challenges persist. Donor contributions to the health sector continue to decline while government contributions are still low. The Health Financing Policy and Strategic Plan were developed with specific strategies to address health financing sustainability challenges. There is a shortage of skilled health professionals; and an increased need for quality health products to ensure an appropriate delivery of health services. Moreover, use of health information is still limited. COOPERATION FOR HEALTH The coordination mechanism of the cooperation for health is under the Health Sector Working Group and different Technical Working Groups chaired by the Ministry of Health. These fora have clear terms of reference and structure, but still need to be reinvigorated. More than 15 actors are operating in the health sector in Rwanda. This comprises bilateral cooperation agencies, international institutions and UN agencies. The main health partners of the Government of Rwanda in terms of funding include the United States of America, the World Bank, the European Union, Belgian Technical Cooperation and the United Nations system. Some Development Partners, such as the One UN, have aligned their procedures and specific requirements on procurement to work in a more streamlined manner. Other DPs like the European Union (EU), African Development Bank (AfDB), and the World Bank provide general budget support (GBS) through Treasury, while others, such as the Belgian Cooperation, earmark their funds to the sector, providing Sector Budget Support (SBS). Other funding modalities include the Global Fund, GAVI, PEPFAR, PMI etc. Rwanda http:// www.who.int/countries/en/ WHO region Africa World Bank income group Low-income Child health Infants exclusively breastfed for the first six months of life (%) (2015) 1 87 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2015) 98 Demographic and socioeconomic statistics Life expectancy at birth (years) (2017) 2 68.1 (Female) 64.6 (Male) 66.4 (Both sexes) Population (in thousands) total (2017) 2 11809.3 % Population under 15 (2017) 2 41.5 % Population over 60 (2017) 2 -5.1 Percentage of population whose total consumption is below the total poverty line per year (RWF 159,375 in January 2014 prices) (2013-14) 7 39.1 Literacy rate among adults aged >= 15 years (%) (-2012 3 68 Gender Inequality Index rank (2015 4 84 Human Development Index rank (2016) 4 159 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 7.53 Private expenditure on health as a percentage of total expenditure on health (2014) 61.9 General government expenditure on health as a percentage of total government expenditure (2015) 5 14 Physicians density (per 1000 population) (2015) 6 0.066 Nursing and midwifery personnel density (per 1000 population) (2015) 6 0.862 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2014-15) 1 20 Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2014-15) 1 50 Maternal mortality ratio (per 100 000 live births) (2014-15) 1 2010 [134 - 287] Births attended by skilled health personnel (%) (2014-15) 1 91% Public health and environment Population using improved drinking water sources (%)2013-14 7 83.7 (Rural) 90.0 (Urban) 84.8 (Total) Population using improved sanitation facilities (%)2013-14 7 93.5 (Urban) 81.3 (Rural) 83.3 (Total) 1 RDHS 2014-15 2 Fourth Population and Housing Census Projections 3 Fourth Population and Housing Census (2012) 4 UNDP reports 5 Mid Term Review of HSSP III (2015) 6 2015 Annual Health Statistics Booklet 7 Fourth Integrated Household Living Conditions Survey (2013-14) GHO - http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (2014–2018) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Support health system strengthening towards health service integration and universal health coverage a) National health policies, strategies and plans: Strengthening the capacity to develop, implement and review a comprehensive national health policy, strategies and plans with adequate mainstreaming of the SDGs principles and targets, especially the Goal 3 and other SDGs with direct or indirect impact on health; Update and implementation of the Health Financing Strategic Plan in line with the Universal Health Coverage (UHC) principles, including CBHI management systems strengthening; HRTT & NHA reporting; and UHC monitoring. b) Access to medicines and health technologies and strengthening regulatory capacity: Establishment of an autonomous medical products regulatory authority; Development of strategies to improve access to medical products and technologies and to promote their rational use; Support to the monitoring of antimicrobials consumption; Identification of research priorities and promotion of research related to health products and technologies; Support to the adoption of WHO technical guidelines, norms and standards relating to quality assurance and safety of health products and technologies ; Capacity building for the implementation of accreditation process of heath related institutions and services. c) Support to the improvement of quantity and quality of human resources for health. d) Health systems, information and evidence: Strengthening of the national health information system capacity toward a good monitoring of health situation and trends taking into account national, regional and global priorities; Development of the country profile and statistical factsheet, Rollout of the National Health Observatory; Strengthening of the regulation of medical records; Capacity building to review and implement the e-Health strategic plan and the National Research Agenda. Support strengthening of Civil Registration and Vital Statistics (CRVS) system as a tool to track progress of the SDG targets. STRATEGIC PRIORITY 2: Contribute to the reduction of morbidity and mortality from major communicable and non-communicable diseases towards consolidation of health related MDG gains and achievement of post 2015 development goals a) Development of new strategic plans and guidelines for both HIV and hepatitis for 2019-2024; capacity building for HIV and hepatitis responses, including monitoring. b) Development of a new TB strategic plan 2019-2024 and revision and update of TB guidelines and capacity building in TB response, including monitoring. c) Development of a malaria strategic plan 2019-2024; and update of strategic information for monitoring of malaria response along with capacity building for case management. d) Implementation of NTD strategic plan; reduction of the morbidity caused by endemic soil-transmitted helminthiasis and schistosomiasis through NTD mapping and deworming campaigns to meet WHO targets for NTD control and elimination by 2020. Non communicable diseases: Development of an intersectoral and decentralized policy and strategy including prevention and management of NCDs; Capacity building of health care providers for prevention and management of NCDs; and development of a national protocol for NCDs. STRATEGIC PRIORITY 3: Contribute to the reduction of maternal newborn and child morbidity and mortality a) Maternal, child and adolescent Health: Review and update of policy and strategies, norms and standards, tools and guidelines to improve the quality of maternal, newborn, child and sexual reproductive health (SRH) including adolescent-friendly SRH services ; Conduct of research, monitoring and evaluation for maternal, child health and SRH; Capacity building for health care providers for quality essential and emergency maternal and newborn care including ECD and PMTCT; Improvement of management of key child health interventions; and strengthening of maternal newborn and child deaths surveillance and response. b) Vaccine preventable diseases: Contribution to the reduction of the under-five mortality rate through the use of community health workers to enhance immunization services; Strengthening of immunization systems including preventable disease surveillance and cold chain management; and support to the introduction of new vaccines. c) Nutrition: Revision of the national protocol on prevention and management of malnutrition; improvement of nutrition surveillance data analysis and results dissemination; Capacity building for prevention and management of malnutrition in children under five and conduct of operational research to strengthen nutrition interventions. STRATEGIC PRIORITY 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety a) Health promotion and the social determinants of health through support to the implementation, monitoring and evaluation of health promotion activities at decentralized level; and promotion of healthy lifestyles addressing NCD risk factors, targeting school ages and other vulnerable groups. b) Promotion of a safer and healthier environment and improved food safety through improved water, sanitation and hygiene services; multisectoral interventions and collaboration addressing the environmental determinants to human health and ecosystem integrity; and strengthening of national and decentralized systems for food safety inspection and risk analysis. STRATEGIC PRIORITY 5: Strengthen disaster risk management and epidemic emergency preparedness and response; and implementation of the International Health Regulations a) Preparedness surveillance and response to outbreaks and crisis: Development of capacity for disaster risk management (DRM) in health sector; Ensuring the availability of relevant policies, strategies and capacities for DRM in the health sector; Strengthening of the use of evidence for early warning, preparedness and response to emergencies and disasters. b) Epidemic infectious diseases: Strengthening capacity to prevent and control epidemic diseases and other public health emergencies through the implementation of an effective and efficient national epidemiological surveillance system. Please note that the 3 rd generation CCS 2014-2018 is being finalize © World Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Rwanda Updated May 2018
HEALTH SITUATION Rwanda has made remarkable socioeconomic progress in the past decade with real GDP growth averaging 8.2% annually. This has translated into improvements in the health situation. Major health reforms took place, including the health insurance improvement, which aims to guarantee access for all to health care; and experience from Rwanda has shown that it is possible to achieve universal health coverage in a country with 90% of its population in the informal sector. Life expectancy has doubled during the 20 years following the devastating 1994 genocide against the Tutsi, as a result of increase in the number of health facilities, improvement in immunization coverage, good access to safe drinking water, and improved housing. All targets related to the three health-MDGs were met, with a notable success in reduction of child mortality and considerable improvements in maternal health The HIV/AIDS national prevalence remains stable at 3% in people between ages 15 and 49; and the country has achieved one of the highest national ART coverage rates in sub-Saharan Africa, reaching 78.2% percent of those eligible for ART based on the new WHO ART guidelines. The current TB prevalence is 85/100 000 people, and the TB mortality rate has been reduced by 81%. Despite these achievements, several health challenges remain. These include malnutrition with 38% of under-five children still stunted. Malaria incidence is also on the rise, from 514,173 cases in 2012 to 1,967,402 cases in 2015. Increase in incidence of NCDs, as a result of the ageing of the population is another issue; along with the financial sustainability of health facilities and services. As consequence of the 1994 genocide against the Tutsi, the country also faces a large burden of mental disorders. Moreover, communicable diseases such as HIV/AIDS, acute respiratory infections, diarrhoeal diseases and tuberculosis account for 90% of complaints at health facilities. To cope with new emerging public health issues like Yellow and Rift Valley Fever, the Ministry of Health developed and implemented an outbreak preparedness and response plan. An electronic IDSR system, that is operational since 2013, was also established. HEALTH POLICIES AND SYSTEMS Based on the Rwandan Constitution, Articles 41 and 45, which states that all citizens have rights and duties relating to health; the country has committed to ensure universal access to affordable promotive, preventive, curative, and rehabilitative health services of the highest attainable quality. In this regard, Rwanda’s Ministry of Health has revised its National Health Policy, based on Vision 2020 and EDPRS II. The health system consists of three levels of service provision: central, intermediary and peripheral. The central level includes the central directorates and programmes of the Ministry of Health and the national referral hospitals. The largest health insurance programme is the Community-Based Health Insurance Scheme (CBHI), estimated to cover 81.4% of the population, and highly subsidized by the GoR. The GoR is committed to implement the post-MDG 2015 development agenda. In addition, high level political commitment, enabling policy and institutional mechanisms are present to address the social determinants of health. There is an agreed joint plan between the GoR, MoH and development partners. A SWAP implementation manual and a road map were developed and endorsed in October 2010, and biennial joint health sector reviews have been held. The Development Partners Coordination Group as a joint mechanism between the GoR and DPs ensures aid coordination and effectiveness. The division of labour arrangement is operational. WHO has ongoing strategic partnerships with key stakeholders in health and other sectors and it will support the health development agenda of the GoR. Under the umbrella of the One UN, WHO is supporting the MOH to develop and implement an SDGs domestication strategy and plan. The organization will engage across all sectors to ensure mainstreaming of health into the other SDGs. The overall policy objective is to strengthen policies, resources and management mechanisms of health support systems to ensure optimal performance of the health programmes so as to achieve the SDGs. Various challenges persist. Donor contributions to the health sector continue to decline while government contributions are still low. The Health Financing Policy and Strategic Plan were developed with specific strategies to address health financing sustainability challenges. There is a shortage of skilled health professionals; and an increased need for quality health products to ensure an appropriate delivery of health services. Moreover, use of health information is still limited. COOPERATION FOR HEALTH The coordination mechanism of the cooperation for health is under the Health Sector Working Group and different Technical Working Groups chaired by the Ministry of Health. These fora have clear terms of reference and structure, but still need to be reinvigorated. More than 15 actors are operating in the health sector in Rwanda. This comprises bilateral cooperation agencies, international institutions and UN agencies. The main health partners of the Government of Rwanda in terms of funding include the United States of America, the World Bank, the European Union, Belgian Technical Cooperation and the United Nations system. Some Development Partners, such as the One UN, have aligned their procedures and specific requirements on procurement to work in a more streamlined manner. Other DPs like the European Union (EU), African Development Bank (AfDB), and the World Bank provide general budget support (GBS) through Treasury, while others, such as the Belgian Cooperation, earmark their funds to the sector, providing Sector Budget Support (SBS). Other funding modalities include the Global Fund, GAVI, PEPFAR, PMI etc. Rwanda http:// www.who.int/countries/en/ WHO region Africa World Bank income group Low-income Child health Infants exclusively breastfed for the first six months of life (%) (2015) 1 87 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2015) 98 Demographic and socioeconomic statistics Life expectancy at birth (years) (2017) 2 68.1 (Female) 64.6 (Male) 66.4 (Both sexes) Population (in thousands) total (2017) 2 11809.3 % Population under 15 (2017) 2 41.5 % Population over 60 (2017) 2 -5.1 Percentage of population whose total consumption is below the total poverty line per year (RWF 159,375 in January 2014 prices) (2013-14) 7 39.1 Literacy rate among adults aged >= 15 years (%) (-2012 3 68 Gender Inequality Index rank (2015 4 84 Human Development Index rank (2016) 4 159 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 7.53 Private expenditure on health as a percentage of total expenditure on health (2014) 61.9 General government expenditure on health as a percentage of total government expenditure (2015) 5 14 Physicians density (per 1000 population) (2015) 6 0.066 Nursing and midwifery personnel density (per 1000 population) (2015) 6 0.862 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2014-15) 1 20 Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2014-15) 1 50 Maternal mortality ratio (per 100 000 live births) (2014-15) 1 2010 [134 - 287] Births attended by skilled health personnel (%) (2014-15) 1 91% Public health and environment Population using improved drinking water sources (%)2013-14 7 83.7 (Rural) 90.0 (Urban) 84.8 (Total) Population using improved sanitation facilities (%)2013-14 7 93.5 (Urban) 81.3 (Rural) 83.3 (Total) 1 RDHS 2014-15 2 Fourth Population and Housing Census Projections 3 Fourth Population and Housing Census (2012) 4 UNDP reports 5 Mid Term Review of HSSP III (2015) 6 2015 Annual Health Statistics Booklet 7 Fourth Integrated Household Living Conditions Survey (2013-14) GHO - http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (2014–2018) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Support health system strengthening towards health service integration and universal health coverage a) National health policies, strategies and plans: Strengthening the capacity to develop, implement and review a comprehensive national health policy, strategies and plans with adequate mainstreaming of the SDGs principles and targets, especially the Goal 3 and other SDGs with direct or indirect impact on health; Update and implementation of the Health Financing Strategic Plan in line with the Universal Health Coverage (UHC) principles, including CBHI management systems strengthening; HRTT & NHA reporting; and UHC monitoring. b) Access to medicines and health technologies and strengthening regulatory capacity: Establishment of an autonomous medical products regulatory authority; Development of strategies to improve access to medical products and technologies and to promote their rational use; Support to the monitoring of antimicrobials consumption; Identification of research priorities and promotion of research related to health products and technologies; Support to the adoption of WHO technical guidelines, norms and standards relating to quality assurance and safety of health products and technologies ; Capacity building for the implementation of accreditation process of heath related institutions and services. c) Support to the improvement of quantity and quality of human resources for health. d) Health systems, information and evidence: Strengthening of the national health information system capacity toward a good monitoring of health situation and trends taking into account national, regional and global priorities; Development of the country profile and statistical factsheet, Rollout of the National Health Observatory; Strengthening of the regulation of medical records; Capacity building to review and implement the e-Health strategic plan and the National Research Agenda. Support strengthening of Civil Registration and Vital Statistics (CRVS) system as a tool to track progress of the SDG targets. STRATEGIC PRIORITY 2: Contribute to the reduction of morbidity and mortality from major communicable and non-communicable diseases towards consolidation of health related MDG gains and achievement of post 2015 development goals a) Development of new strategic plans and guidelines for both HIV and hepatitis for 2019-2024; capacity building for HIV and hepatitis responses, including monitoring. b) Development of a new TB strategic plan 2019-2024 and revision and update of TB guidelines and capacity building in TB response, including monitoring. c) Development of a malaria strategic plan 2019-2024; and update of strategic information for monitoring of malaria response along with capacity building for case management. d) Implementation of NTD strategic plan; reduction of the morbidity caused by endemic soil-transmitted helminthiasis and schistosomiasis through NTD mapping and deworming campaigns to meet WHO targets for NTD control and elimination by 2020. Non communicable diseases: Development of an intersectoral and decentralized policy and strategy including prevention and management of NCDs; Capacity building of health care providers for prevention and management of NCDs; and development of a national protocol for NCDs. STRATEGIC PRIORITY 3: Contribute to the reduction of maternal newborn and child morbidity and mortality a) Maternal, child and adolescent Health: Review and update of policy and strategies, norms and standards, tools and guidelines to improve the quality of maternal, newborn, child and sexual reproductive health (SRH) including adolescent-friendly SRH services ; Conduct of research, monitoring and evaluation for maternal, child health and SRH; Capacity building for health care providers for quality essential and emergency maternal and newborn care including ECD and PMTCT; Improvement of management of key child health interventions; and strengthening of maternal newborn and child deaths surveillance and response. b) Vaccine preventable diseases: Contribution to the reduction of the under-five mortality rate through the use of community health workers to enhance immunization services; Strengthening of immunization systems including preventable disease surveillance and cold chain management; and support to the introduction of new vaccines. c) Nutrition: Revision of the national protocol on prevention and management of malnutrition; improvement of nutrition surveillance data analysis and results dissemination; Capacity building for prevention and management of malnutrition in children under five and conduct of operational research to strengthen nutrition interventions. STRATEGIC PRIORITY 4: Promote health by addressing social determinants of health, health and environment, nutrition and food safety a) Health promotion and the social determinants of health through support to the implementation, monitoring and evaluation of health promotion activities at decentralized level; and promotion of healthy lifestyles addressing NCD risk factors, targeting school ages and other vulnerable groups. b) Promotion of a safer and healthier environment and improved food safety through improved water, sanitation and hygiene services; multisectoral interventions and collaboration addressing the environmental determinants to human health and ecosystem integrity; and strengthening of national and decentralized systems for food safety inspection and risk analysis. STRATEGIC PRIORITY 5: Strengthen disaster risk management and epidemic emergency preparedness and response; and implementation of the International Health Regulations a) Preparedness surveillance and response to outbreaks and crisis: Development of capacity for disaster risk management (DRM) in health sector; Ensuring the availability of relevant policies, strategies and capacities for DRM in the health sector; Strengthening of the use of evidence for early warning, preparedness and response to emergencies and disasters. b) Epidemic infectious diseases: Strengthening capacity to prevent and control epidemic diseases and other public health emergencies through the implementation of an effective and efficient national epidemiological surveillance system. Please note that the 3 rd generation CCS 2014-2018 is being finalize © World Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Rwanda Updated May 2018