Thirty Years of Rwandan-German Development Cooperation

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Thirty Years of Rwandan-German Development Cooperation 1 VOLUME I: EVALUATION REPORT Thirty Years of Rwandan-German Development Cooperation in the Health Sector 2014 The German Institute for Development Evaluation (DEval) is mandated by the German Federal Ministry for Economic Cooperation and Development (BMZ) to independently analyse and assess German development interventions. The evaluations of the institute aim to make contributions which improve the grounds for decision-making necessary for effectively shaping development policy and which increase the transparency of evaluation results. The report presented here can be downloaded in pdf-format from the DEval-website under: www.deval.org/en/evaluation-reports. Please forward any requests for publications in print to [email protected]. All views presented in this report are from DEval and do not necessarily represent the positions of the BMZ. A statement from the BMZ regarding this evaluation is available under: www.bmz.de/bmz-stellungnahmen-deval-evaluierungen. Contact German Institute for Development Evaluation (DEval) Tulpenfeld 7, 53113 Bonn Germany www.DEval.org Dr. Stefanie Krapp Tel: +49 (0)228 24 99 29-930 Email: [email protected] The report consists of two volumes: Volume I: Evaluation Report Volume II: Annexes Authors Dr. Thomas Schwedersky Dr. Martin Noltze Felix Gaisbauer Responsible Dr. Stefanie Krapp Acknowledgement DEval would like to thank all interviewees, reference groups, the Rwandan Ministry of Health, the German Embassy, the German Federal Ministry for Economic Cooperation and Development (BMZ), and implementing agencies for their explicit and valuable support of the evaluation. Executive Summary vi EXECUTIVE SUMMARY Background, objectives, and methodology conditions within the sector and with regard to socioeconom- ic and political developments. In accordance with the Paris Declaration on Aid Effectiveness 4. The phasing out of GDC in the health sector. and the Accra Agenda for Action, the Government of Rwanda has enhanced the division of labor between the donors that support To reduce the complexity inherent in the time period covered Rwanda. In 2010, as a consequence, the German Federal Gov- by the evaluation, German interventions in the Rwandan health ernment agreed to the request of the Government of Rwanda to sector have been reviewed for paradigmatic shifts that would discontinue its support to the health sector by the end of 2012. allow for a temporal disaggregation for this period. Mapping This has provided a unique opportunity to review and assess 30 the interventions between 1980 and 2012, according to (1) the years of cooperation in the Rwandan health sector by means of a implementing agency, (2) their duration, (3) the mode of delivery summative evaluation. There is an overarching interest in striking and strategic alignment, and (4) thematic focus, has implied that a balance after so many years of cooperation, based on an array 1994 / 1995 and 2003 / 2004 can be considered turning points. In of aid modalities and instruments of German Development addition, the 1994 Rwandan genocide marks a period sufficiently Cooperation (GDC) (project- and program-based approaches, serious to require consideration. The year 2003 constitutes the basket funding and sector budget support, policy dialogue, onset of a transformation within Rwandan-German development technical assistance – including advisory services and training cooperation from the standpoint of project-mode to a more – and financial cooperation (provided by GTZ / GIZ, DED / GIZ, integrated form of cooperation. Accordingly, the analysis has InWEnt / GIZ, and KfW), which have come into play. focused on three phases: (I) 1980 – 94, (II) 1995 – 2003 and (III) 2004 – 12. The evaluation was conducted by DEval between July 2012 and October 2013.1 The results shed light on how development Phases I and II, in particular, posed challenges regarding the cooperation in one sector (health) has developed over many availability of interview partners, relevant documentation, and years, while experiencing changing political and socioeconomic secondary data. While emphasis was placed on documenting the contexts and aid modalities. By documenting the entire process, evolution of Rwandan-German cooperation and the adaptation including the phasing out and identifying of successful approach- to changing situations during these phases, the focus of Phase es, Rwandan partners can use the findings for their own man- III was to provide evidence for a theory-based evaluation design, agement of the health sector and their cooperation with other based on the criteria of the Development Assistance Committee development partners. GDC, at the same time, can draw lessons of the Organisation for Economic Cooperation and Development for future support to sector development in partner countries. (OECD-DAC): relevance, effectiveness, efficiency, impact, and sustainability. In addition, the design would include criteria The specific objectives of the evaluation are to provide evidence formulated by the German Ministry for Economic Cooperation and an assessment of the following: and Development (BMZ): coherence, complementarity, coordi- nation, and harmonization. Evaluation approaches for attributing 1. How Rwandan-German cooperation has developed in the health effects in the Rwandan population to German support health sector. had proved unachievable due to program implementation 2. The relevance, effectiveness, efficiency, impact, sustainability, design. While advantageous, according to the aid effectiveness coherence, coordination, complementarity, and harmoniza- model, the significant alignment to national health priorities tion of Rwandan-German cooperation in the health sector. further complicated attribution analysis and, therefore, led to 3. Successful and less successful aid modalities and instruments, the adoption of a theory-based contribution analysis. Further as well as their interaction and adaptability to changing key questions with regard to the evaluation of Phase III relate to 1 The draft of the evaluation report was sent to the reference groups on October 31st, 2013. vii Executive Summary the phasing out of Rwandan-German cooperation with regard family planning activities, in any case, cannot be viewed in to health and the assignment of the different aid modalities and opposition to government interests, since the regime appeared instruments and their interaction. to unconditionally support family planning. The following methods have been applied: (1) document analysis; German development workers, during this phase, primarily (2) standardized online survey among former development worked to fill the human resources gaps in the rural health workers; (3) interviews with different groups of key stakeholders; sector. They considered the high staff turnover in the public (4) statistical data analysis of the most recent Demographic and health system and the increased movement of labor to the Health Survey in Rwanda; and (5) a comparative case study of private sector as major factors hindering development. four district health systems, using focus group discussions and qualitative interviews. Discriminatory treatment of staff in the health sector – based on ethnic group – took place, as well as in daily work life. The Key findings and conclusions interviews that were conducted, however, do not point to open discrimination in the treatment of patients; rather, they point to Rwandan-German cooperation between 1980 and 1994 discrimination based on a patient’s socioeconomic situation. (Phase I) The political situation during this period of Rwandan-German The already volatile socioeconomic situation further deteriorated cooperation was characterized by an ideology centered on the when the regime of Juvénal Habyarimana was attacked by the idealization of rural farmers and their manual work, represented Rwandese Patriotic Army in 1990. In 1993, the Arusha Accords by the majority ethnic group. This ideology came under con- ended the three-year civil war, but the negotiated power-sharing siderable pressure at the end of the 1980s, when commodity agreements between the Government of Rwanda and the Rwan- prices – especially for coffee – fell and the price for imported dese Patriotic Front were only slowly implemented and did not goods increased, partly as a result of the World Bank’s structural halt the violence. The ethnically loaded conflict peaked in April adjustment programs. Not only did this challenge food security 1994, when Hutu extremists seized power within hours after the and nutrition; it also impacted on the economic situation of assassination of Habyarimana, and a state-orchestrated genocide Rwandan households and had severe implications on the health began, resulting in a tremendous death toll. of the population. GDC reaction to this socioeconomic deteriora- tion has been limited. The motivation for change originated more GDC interventions did not change, in essence, during the first so from the individual initiatives of development workers in their phase. While there was a call for attention from within GDC and work place rather than from the directions of GDC organizations. internationally on the increasing conflict, GDC misjudged the situation and reacted on the outbreak of violence only by evac- In accordance with its mandate, GDC contributed to an improve- uating all German project staff. GDC personnel began returning ment in health services, especially maternal and child health to Rwanda in March 1995, when it became evident that nearly all care and
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