The “exit strategy” of the Rwandan-German health programme
Development practitioners are usually busy designing new programmes. Sometimes, however, it is time to end a programme. Full stop. Even though phasing-out rarely receives a lot of attention, in order to maximise impact and sustainability it may be indeed as challenging and important as starting a programme. The experience of Rwandan-German cooperation in health, which recently ended after 35 years, offers some insights into how to address this challenge.
The Rwanda-German health programme
Rwandan-German cooperation in health started in 1978. In recent years, the programme implemented by KfW and GIZ notably contributed to the following successes of Rwanda’s health sector:
- High health insurance coverage leading to better access of the poor to health services. German cooperation provided technical support to the development of the community-based health insurance (“mutuelles”) that covers today 91% of the population.
- Increased use of contraceptives resulting in a decline in fertility and the stabilisation of HIV rates. The programme funded the social marketing of contraceptives and campaigns to encourage behaviour change.
- A sound policy framework for the health sector. The programme supported the development and implementation of important national strategies, notably on sexual and reproductive health of adolescents, family planning, human resource development, gender-based violence and maintenance of medical equipment.
- Improved aid effectiveness and government ownership. German cooperation was closely aligned to national strategies and used joint planning, sector budget support and pooled funds.
The “exit strategy”
In 2010, the Government of Rwanda proposed a division of labour among development partners in order to improve aid effectiveness in the spirit of the Paris Declaration. Germany welcomed this initiative. It was jointly decided that bilateral cooperation in health would phase out by 2012/2013 and that German support would concentrate on three other sectors. As part of the phasing-out process, the two governments also decided to commission an external evaluation of 35 years of cooperation.
How did the programme and its partners implement this decision? In 2011, the programme scaled down support in some areas already. The programme also changed its way of planning and monitoring by introducing, for each area of support, clear “milestones” to be achieved by the end of 2012. This system enabled technical advisors to concentrate on what was necessary to ensure a sustainable exit. The main partner, Rwanda’s Ministry of Health, agreed upon this “exit strategy” and other development partners were informed.
In early 2012, the gradual reduction and final end of support was factored into the joint annual planning with partners in the Ministry and in the 5 partner districts and 7 partner hospitals at local level. By mid-2012, programme officials discussed detailed handing-over options with concerned units in the Ministry of Health and with the development partners group. Ministry representatives also joined the discussions with each district and hospital partner. This was important to support partners at local level that have more limited capacity to take over activities or find alternative support on their own.
The hard work done, a more festive, but not less important, part followed. The programme visited each partner district during a “roadshow” to look back at achievements, share memories and say good-bye. A final event of all Rwandan and development partners took place in Kigali, themed “looking back and thinking ahead”, where participants also discussed future challenges facing Rwanda’s health sector and its partners.
What can we learn from this experience? First of all, the phasing-out decision itself was underpinned by mutual agreement, strong country ownership and a reasonable transition period. Secondly, accompanying the process by an independent evaluation was important to provide for mutual accountability and shared learning. Thirdly, a gradual approach to scaling-down activities proved important, particularly the timely development of clear milestones to be achieved by the end of the 2 year transition period. Yet the process also showed that painful decisions had to be taken at some point and that this concerned mainly district-level partners who have restricted budgets and capacities. In this regard, it was important to closely involve both the Ministry of Health and all other developments partners. This, in turn, was only possible because of Rwanda’s health sector-wider approach (SWAp).
- Publication “Building a healthy Rwanda. 35 years of Rwandan-German Cooperation in health” (PDF, 44 pp. 2.4 MB)
- Film “Building a healthy Rwanda. 35 years of Rwandan-German Cooperation in health”
- Publication Background note and programme of the closing event in Kigali (PDF, 3 pp. 286 KB)