Findings of the independent evaluation of Rwandan-German cooperation in health

The German Institute for Development Evaluation (DEval) has published a major evaluation report on 30 years of Rwandan-German cooperation in health. We spoke to Thomas Schwedersky, senior evaluation specialist at DEval and one of the lead authors, about the main findings and lessons, in particular with regard to program-based approaches, health financing, sexual and reproductive health and rights, and human resource development.

Evaluation of Rwandan-German cooperation in health

Ruhengeri Hospital, Rwanda (Picture. GIZ / Viktoria Rabovskaja)

Background: In accordance with the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, the Government of Rwanda has enhanced the division of labor between the donors that support Rwanda. In 2010, as a consequence, the German Federal Government agreed to the request of the Government of Rwanda to discontinue its support to the health sector by the end of 2012. This has provided a unique opportunity to review and assess 30 years of cooperation in the Rwandan health sector by means of a summative evaluation. The evaluation was conducted by DEval between July 2012 and October 2013.  At DEval’s website, you can access the evaluation report in English and in German and a reaction by BMZ (in German) can be found here.

How did you approach the enormous task of evaluating more than 30 years of Rwandan-German Cooperation in the health sector?

Schwedersky: We had to manage the complexity inherent in the long period of more than 30 years of Rwandan-German cooperation in the health sector by identifying different phases marked by paradigm shifts. Accordingly, our evaluation has focused on three phases: (I) 1980 – 1994, (II) 1995 – 2003 and (III) 2004 – 2012. These phases have been identified in consultation with the reference groups – one in Rwanda and one in Germany –having been established for accompanying the evaluation process. Phases I and II, in particular, posed challenges regarding the availability of interview partners, relevant documentation, and secondary data. However, we were able to get evidence from former German development workers, through a survey in combination with in-depth interviews, and from former Rwandan health professionals about the evolution of Rwandan-German cooperation and the adaptation to changing situations during these phases. This was backed up by the analysis of secondary data.  

For this evaluation, we definitely put an emphasis on phase III (2004 – 2012) for which we adopted a theory-based evaluation design with a comparative case study of four district health systems, using focus group discussions and qualitative interviews, as one of the key methodological features. The main challenge regarding this phase has been for us to adequately evaluate a program having multiple components and intervention levels and operating in the multi-donor environment of a sector-wide approach under strong national ownership. In order to cope with this challenge we adopted contribution analysis as a means to assess the contributions of German Development Cooperation to the program-based approach in the health sector in Rwanda.

Could you tell us about the main findings of the evaluation?

Looking at the whole period of Rwandan German cooperation in the health sector allowed us to show how several instruments and aid modalities have emerged. Throughout this period, there has been a trend from fragmented and decentralized service delivery towards program-based health system‘s strengthening covering three components: health financing, sexual and reproductive health and human resource development.

Efforts of German Development Cooperation in making program-based structures and mechanisms functioning well have been highly effective. However, the corresponding structures and mechanisms at the decentralized level, the so-called district health management teams and joint action development forums, are not yet sufficiently functional. While joint financing modalities, namely sector budget support and basket funding, were supported by German Development Cooperation the potential of these aid modalities could not be fully explored  due to a limited leverage effect and the lack of coherence among contributing development partners.

There is an impressive trend of increasing coverage rates of the community-based health insurance scheme in Rwanda (currently about 90 % of the Rwandan population is covered) to which German Development Cooperation has contributed very effectively. Performance-based financing is another key feature for health system strengthening having been supported by Rwandan-German Cooperation.  The evidence gathered confirms that performance-based financing increased service orientation and the output of health professionals, but it also suggests that negative motivational side effects did occur and prevalent resource constraints hindered achieving these outputs and resource constraints are real.

As far as human resource development is concerned German Development Cooperation has contributed in a highly effective manner to increase the number of Rwandan health professionals and to enhance their skills and knowledge. The continuation of the internship program, i.e. the on-the-job training of graduated medical doctors, is a long-lasting positive and systems-building effect of German Development Cooperation support, despite the organizational challenges it still faces. Scaling-up efforts have been achieved with the establishment of the hospital management task force and the country-wide training of hospital administrators.

Regarding sexual reproductive health German development cooperation contributed to health service delivery by significantly improving (1) antenatal care, (2) clinic-based deliveries and post-natal care, (3) HIV testing and counseling (including voluntary counseling and testing), (4) coverage of antiretroviral treatment, and (5) treatment of tuberculosis.

Moreover, the combination of information campaigns with commercial marketing techniques for contraceptives through private sector social marketing has appeared to effectively contribute to awareness raising and attitude and behavior change

However, sexual reproductive health faces persistent future challenges due to the continuing limited technical capacities of health professionals and the considerable disparities with regard to service utilization throughout the population.

What are the main lessons for other health programs of German Development Cooperation?

The main lessons derived from this evaluation cannot claim general transferability or applicability. They should, therefore, serve as input for the design, implementation, and phase out of program-based approaches, especially in relation to the health sector, in partner countries with similar conditions to those prevailing in Rwanda.

To increase the effectiveness of sector-wide approaches , not only to the health sector, future strategies should put more emphasis on improving coherence among development partners, especially with regard to joint financing modalities.

Regarding health financing we recommend that future interventions regarding performance-based financing should be combined more systematically with capacity development for supervision and managerial staff with, at best, interventions to improve the physical work environment. Otherwise, the goals and indicators established will be perceived as unachievable and may lead to lack of motivation or false reporting of goal achievement.

For future social marketing strategies under similar conditions, German Development Cooperation should put a special emphasis on providing advice to clarify the roles and responsibilities between the public and private sectors, in order to enhance the potential for commercial marketing techniques and to decrease the costs to the public health system.

To further strengthen future health system programs, more emphasis should be placed on supporting medical education in partner countries, hand in hand with policy dialogue. This will strengthen the commitment of partner countries to allocate sufficient financial and human resources to medical education.

Thank you.


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