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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Evaluation of PEPFAR’s
Contribution (2012–2017)
to

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Committee on the Evaluation of Strengthening Human Resources for
Health Capacity in the Republic of Rwanda Under the President’s
Emergency Plan for AIDS Relief (PEPFAR)

Board on Global Health

Health and Medicine Division

A Consensus Study Report of

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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This activity was supported by a contract between the National Academy of Sciences and the U.S. Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR’s contribution (2012–2017) to Rwanda’s Human Resources for Health Program. Washington, DC: The National Academies Press. https://doi.org/10.17226/25687.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process, and it represents the position of the National Academies on the statement of task.

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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COMMITTEE ON THE EVALUATION OF STRENGTHENING HUMAN RESOURCES FOR HEALTH CAPACITY IN THE REPUBLIC OF RWANDA UNDER THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF (PEPFAR)

ANN E. KURTH (Chair), Linda Koch Lorimer Professor and Dean, Yale School of Nursing

TILL BÄRNIGHAUSEN, Alexander von Humboldt University Professor and Director, Heidelberg Institute of Global Health, University of Heidelberg, Germany; Adjunct Professor of Global Health, Harvard T.H. Chan School of Public Health

ERAN BENDAVID, Associate Professor of Medicine, Stanford University

CARLA CASTILLO-LABORDE, Assistant Professor, Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile

ELVIN H. GENG, Professor of Medicine, Division of Infectious Diseases, and Director of the Center for Dissemination and Implementation at the Institute for Public Health, Washington University in St. Louis

FASTONE M. GOMA, Dean and Associate Professor, University of Zambia School of Medicine, Lusaka, Zambia

LAURA HOEMEKE, Global Health Policy Consultant; Adjunct Professor, Gillings School of Global Public Health, University of North Carolina at Chapel Hill

ANGELINA KAKOOZA-MWESIGE, Senior Lecturer and Pediatric Neurologist, Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda

EMMANUEL B. K. LUYIRIKA, Executive Director, African Palliative Care Association, Kampala, Uganda

MOSA MOSHABELA, Dean and Head, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

DENIS NASH, Distinguished Professor and Executive Director, CUNY Institute for Implementation Science in Population Health, City University of New York Graduate School of Public Health and Health Policy

CHARLES OK PANNENBORG, Retired Chief Health Advisor and Chief Health Scientist, The World Bank Group

DEREK J. SLOAN, Senior Clinical Lecturer and Consultant Infectious Diseases Physician, University of St. Andrews, Scotland

SHEILA D. TLOU, Chair, Global HIV Prevention Coalition; Former Director of the Regional Support Team for Eastern and Southern Africa, UNAIDS (until May 2019)

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Study Staff

SUSAN F. E. MILNER, Study Director

CECILIA MUNDACA SHAH, Senior Program Officer (until December 2018)

KATYE M. MAGEE, Associate Program Officer (until February 2019)

EMMA FINE, Associate Program Officer (from May 2019)

T. ANH TRAN, Research Associate (until March 2020)

ZARIA FYFFE, Senior Program Assistant (from March 2020)

MICHELLE KVALSUND, National Academy of Medicine Fellow in Osteopathic Medicine

JULIE A. PAVLIN, Senior Director, Board on Global Health

Consultant

BRIDGET B. KELLY, Principal Consultant, Burke Kelly Consulting

EnCompass LLC Consulting Team

SARAH SMITH LUNSFORD, Team Lead and Senior Evaluation Specialist

SIMON HILTEBEITEL, Monitoring and Evaluation Specialist II

KELSEY SIMMONS, Evaluation Specialist II

AMY BHOPAL, Special Projects Associate

REBECCA K. CATHCART, Rwanda-Based Consultant

SYLVESTRE MUSENGIMANA, Rwanda-Based Consultant

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

PAULIN BASINGA, Bill & Melinda Gates Foundation

MOLLY COOKE, University of California, San Francisco

SUNDEEP K. GUPTA, Partners in Hope, Malawi

WILLIAM HOLZEMER, Rutgers University

RICHARD MARLINK, Rutgers Global Health Institute

SANGEETA MOOKHERJI, The George Washington University

KHAMA ROGO, World Bank

KIMBERLY A. SCOTT, Virginia Department of Health

JEAN N. UTUMATWISHIMA, Rwamagana Provincial Hospital

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by KRISTINE M. GEBBIE, Flinders University School of Nursing and Midwifery, and ANN M. ARVIN, Stanford University School of Medicine. They were responsible

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Preface

The world needs more health workers. The need is acute in low-income country settings with the highest burden of HIV disease, including in sub-Saharan Africa. With 11 percent of the world’s population, 24 percent of the global disease burden, and more than 70 percent of HIV disease,1 yet only 3 percent of the world’s health workforce, this region is ripe for innovation and investment to improve human resources for health (HRH).2 Given this context, the Rwanda HRH Program was an important experiment, one that arose from a unique set of circumstances—a postgenocide need to rebuild, impressive advancement in addressing baseline HIV metrics, and a government dedicated to improving Rwandan health via creation of a stronger and more self-sustaining health system.

The President’s Emergency Plan for AIDS Relief (PEPFAR) and its leadership in the Office of the U.S. Global AIDS Coordinator are mandated to address HIV, and the Government of Rwanda has a commitment to improve the health of all of its people. These goals may seem to be in conflict—a vertical focus on a single disease and a horizontal approach to building a health system able to address all citizens’ basic health needs. The debate over vertical versus horizontal programming has been an ongoing

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1 Kharsany, A. B. M., and Q. A. Karim. 2016. HIV infection and AIDS in sub-Saharan Africa: Current status, challenges and opportunities. Open AIDS 10.

2 IFC (International Finance Corporation). 2019. Sub-Saharan Africa: Health and education. https://www.ifc.org/wps/wcm/connect/REGION__EXT_Content/IFC_External_Corporate_Site/Sub-Saharan+Africa/Priorities/Health+and+Education (accessed November 6, 2019).

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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one; however, given the growing burden of noncommunicable diseases (accounting for 71 percent of global mortality)3 and the evolution of managing HIV disease as a chronic care model with multiple comorbidities, there may be increasing congruence. In this context, we must admire the creativity of PEPFAR and the Government of Rwanda in partnering to launch this distinctive program.

The Rwanda HRH Program experiment is one from which we believe salient lessons can be drawn for the design and implementation of workforce capacity building that advances both HIV prevention and care and country attainment of universal health access and coverage. Many countries and collaborations can learn from the way the HRH Program was conceived, executed, and evaluated. These lessons are especially timely given the commitment made at the United Nation’s first high-level meeting on universal health coverage (UHC) on September 23, 2019, which recognized the substantial shortfall of workers in low- and middle-income countries and “the need to train, build, and retain a skilled health workforce,” noting in particular “nurses, midwives, and community health workers.”4

Perhaps a primary lesson of the Rwanda HRH paradigm is the limited time line of the Program, foreshortened as it was by a 2-year reduction in PEPFAR funding. Even the original conception of a program designed for less than a decade was arguably too brief to create cohorts of expert clinicians who could be educated, practice and have an impact on care, and educate the next generation of clinicians in turn. Another key lesson is that the degree of structural change needed for sustained gains in institutional capacity for health professional education was underestimated. Likewise, faculty development to take on this work at the University of Rwanda was not as grounded in partnership engagement as it could have been.

Given the vertical mission of PEPFAR, the goal to understand whether the HRH Program funding improved outcomes for people living with HIV (PLHIV) is logical. As a committee, we thought deeply about how one might attempt to answer this as an overarching evaluation question, given the lack of baseline and time-series data, the too brief period of funded work, and the challenges of navigating between a vertical focus on HIV outcomes and a more horizontal nation-building program of health workforce advancement. The committee’s final conclusion was that it would not be possible to determine attribution. But given the continued HIV epidemic in sub-Saharan Africa, as well as the issue of how best to achieve UHC

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3 WHO (World Health Organization). 2018. Noncommunicable diseases. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (accessed November 6, 2019).

4 United Nations. 2019. Political declaration of the high-level meeting on universal health coverage: “Universal health coverage: Moving together to build a healthier world.” New York: United Nations. https://undocs.org/en/A/RES/74/2 (accessed January 28, 2020).

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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worldwide, this evaluation was an opportunity to highlight the importance of HRH and how it can affect not only PLHIV, but ultimately everyone’s health.

The study was completed in a relatively accelerated time frame, but with thoughtfulness and methodologic depth. Following from our commitment to learn as much as possible, despite the limitations due to the circumstances of this Program and this evaluation, the committee offers not only findings about this Program, but also suggestions for how future endeavors such as this could be designed to more explicitly enable learning to follow from innovation.

We are deeply grateful for the work of the dedicated staff, consultants, and committee members, and most of all to the Rwandan government representatives and university employees, faculty who participated through U.S. partner institutions, and others throughout the country who participated in this evaluation. We invite the reader to consider ways to apply the lessons to their own work to improve the health of people and populations.

Ann E. Kurth, Chair

Committee on the Evaluation of Strengthening Human Resources for Health Capacity in the Republic of Rwanda Under the President’s Emergency Plan for AIDS Relief (PEPFAR)

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Acknowledgments

This Consensus Study Report and program evaluation would not have been possible without the invaluable contributions of many individuals. First and foremost, the committee, consultants, and study staff wish to express their sincere appreciation to the 87 anonymous respondents who so generously gave their time to provide their insights during the study’s qualitative interviews.

We also wish to express our sincere thanks to the speakers, listed in Appendix B, and other participants at the committee’s public sessions in Washington, DC, and Kigali, Rwanda, for their time and their willingness to share with us their various perspectives.

In addition, we are grateful to Dr. Khama Rogo and Dr. Daniel Yumbya for providing insight and guidance on the health professional education systems and accreditation processes in East Africa.

We are profoundly grateful to the leadership and staff at the Rwandan Ministry of Health, Rwanda Biomedical Center, University of Rwanda, Rwanda Medical Association, and Rwanda Nurses and Midwives Union for providing the data presented in this study and for their thoughtful input and cooperation. Without the support and commitment, at every juncture, of Dr. Diane Gashumba, Dr. Jean Pierre Nyemazi, Dr. Sabin Nsanzimana, Mr. Joseph Shema, Dr. Parfait Uwaliraye, Dr. Patrck Ndimubanzi, Dr. Jeanine Condo, Dr. Phil Cotton, Dr. David Ntirushwa, and Mr. Andre Gitembagara this report would not have been possible.

We are extremely appreciative of the efforts of Dr. Kristine Gebbie, who twice oversaw reviews of this study, first at the protocol stage and later as a

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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final manuscript. In addition, we are indebted to the following individuals who gave generously of their time and expertise to review the study’s protocol in December 2018: Dr. Sangeeta Mookherji, The George Washington University; Dr. Sam Phiri, Lighthouse Trust, Malawi; Dr. Shoshanna Sofaer, City University of New York; Dr. Allison P. Squires, New York University; and Dr. Kathryn Whetten, Duke University.

We also wish to thank staff with the President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC) Rwanda and with CDC Atlanta, most especially Ms. Emma Mtiro, for their support and guidance over the course of the study.

Finally, many within the National Academies of Sciences, Engineering, and Medicine also provided assistance with the study. We would like to thank Rebecca Morgan with the National Academies’ Research Center staff for her assistance with research. We also wish to thank Ron Brown, Daniel Cesnalis, Anna Isabel Camilo Javier, Julie Wiltshire, and Skip Day (Office of the Chief Financial Officer); Lauren Shern, Taryn Young, and Bettina Seliber (HMD Executive Office); Maryjo Oster and Dorothy Zolandz (Report Review Committee); Marc Gold (Office of the General Counsel); Andrew Grafton, Greta Gorman, Nicole Joy, Jeanay Butler, and Sadaf Faraz (Office of Communications); and Stephanie Miceli (Office of News and Public Information).

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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6-1 Doctors, nurses, and midwives per 10,000 population

6-2 Total physician specialists graduated under the HRH Program by year

6-3 Total nursing specialists graduated under the HRH Program by specialty

6-4 Career trajectory of interviewed HRH Program graduates following graduation

6-5 Career trajectory of interviewed HRH Program trained nursing respondents

6-6 Distribution of sites receiving health professional education equipment through PEPFAR support under the HRH Program by district

7-1 HIV prevalence among Rwandan adults aged 15–49

7-2 Antiretroviral therapy coverage, 2010–2017

7-3 New HIV infections, 1990–2018

7-4 PMTCT need and number of pregnant women on ARVs, 2011–2016

7-5 Data-driven causal pathway

TABLES

1-1 HIV Prevalence and ART Coverage in Surrounding Countries in the Eastern and Southern African Regions, 2012

2-1 HIV Prevalence and ART Coverage in Facility Microsystem Districts

2-2 Interview Respondent Sample

2-3 Interview Topics by Respondent Type

3-1 PEPFAR Funding Sources That Contributed to the HRH Program

3-2 HRH Program Budget by Year (U.S. Dollars)

3-3 CDC Disbursements for the HRH Program by Year (U.S. Dollars)

3-4 Ministry of Health Budget and Expenditures Reported Preceding and During the HRH Program (U.S. Dollars, Rounded to Millions)

3-5 MOH Health Workforce Expenditures with Category Breakdowns by Year (U.S. Dollars)

3-6 Evolution of the HRH Program’s Goals and Approaches

3-7 HRH Program Expenditures of PEPFAR Investments (U.S. Dollars)

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Acronyms and Abbreviations

APEFE Association pour la Promotion de l’Éducation et de la Formation à l’Etranger
ART antiretroviral therapy
ARV antiretroviral (drug)
BSN Bachelor of Science in Nursing
CD4 cluster of differentiation 4
CDC U.S. Centers for Disease Control and Prevention
CHAI Clinton Health Access Initiative
CHUB Centre Hospitalier Universitaire de Butare/University Teaching Hospital, Butare
CHUK Centre Hospitalier Universitaire de Kigali/University Teaching Hospital, Kigali
CHW community health worker
CMHS College of Medicine and Health Sciences
COP country operational plan
COSECSA College of Surgeons of East, Central, and Southern Africa
CPD continuing professional development
ESTHER Ensemble pour une solidarité thérapeutique hospitalière en réseau/Network for Therapeutic Solidarity in Hospitals
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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FCS(ECSA) Fellowship of the College of Surgeons of East, Central, and Southern Africa
FY fiscal year
GDP gross domestic product
GHWA Global Health Workforce Alliance
GP general practitioner
HRH human resources for health
HSS health systems strengthening
HSSP IV Health Sector Strategic Plan 4
LMIC low- and middle-income country
M&E monitoring and evaluation
MDG Millennium Development Goal
MHA Master of Hospital and Healthcare Administration
MIFOTRA Ministry of Public Service and Labour
MINECOFIN Ministry of Finance and Economic Planning
M.Med. Master of Medicine
MOE Ministry of Education
MOH Ministry of Health
MOU memorandum of understanding
MSN Master of Science in Nursing
NGO nongovernmental organization
NISR National Institute of Statistics of Rwanda
PEPFAR President’s Emergency Plan for AIDS Relief
PLHIV people living with HIV
PMTCT prevention of mother-to-child transmission
PrEP preexposure prophylaxis
RBC Rwanda Biomedical Center
RPHIA Rwanda Population-Based HIV Impact Assessment
RWF Rwandan Francs
Sida Swedish International Development Cooperation Agency
SMART specific, measurable, achievable, relevant, and time-based
SPH School of Public Health
SPIU Single Project Implementation Unit
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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TAGGS Tracking Accountability in Government Grants
TDF tenofovir disoproxil fumarate
THET Tropical Health Education Trust
UGHE University of Global Health Equity
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIV/AIDS
USAID United States Agency for International Development
USD U.S. dollar
USI U.S. institution
WHO World Health Organization
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program. Washington, DC: The National Academies Press. doi: 10.17226/25687.
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Since 2004, the U.S. government has supported the global response to HIV/AIDS through the President’s Emergency Plan for AIDS Relief (PEPFAR). The Republic of Rwanda, a PEPFAR partner country since the initiative began, has made gains in its HIV response, including increased access to and coverage of antiretroviral therapy and decreased HIV prevalence. However, a persistent shortage in human resources for health (HRH) affects the health of people living with HIV and the entire Rwandan population.

Recognizing HRH capabilities as a foundational challenge for the health system and the response to HIV, the Government of Rwanda worked with PEPFAR and other partners to develop a program to strengthen institutional capacity in health professional education and thereby increase the production of high-quality health workers. The Program was fully managed by the Government of Rwanda and was designed to run from 2011 through 2019. PEPFAR initiated funding in 2012. In 2015, PEPFAR adopted a new strategy focused on high-burden geographic areas and key populations, resulting in a reconfiguration of its HIV portfolio in Rwanda and a decision to cease funding the Program, which was determined no longer core to its programming strategy. The last disbursement for the Program from PEPFAR was in 2017.

Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program describes PEPFAR-supported HRH activities in Rwanda in relation to programmatic priorities, outputs, and outcomes and examines, to the extent feasible, the impact on HRH and HIV-related outcomes. The HRH Program more than tripled the country’s physician specialist workforce and produced major increases in the numbers and qualifications of nurses and midwives. Partnerships between U.S. institutions and the University of Rwanda introduced new programs, upgraded curricula, and improved the quality of teaching and training for health professionals. Growing the number, skills, and competencies of health workers contributed to direct and indirect improvements in the quality of HIV care. Based on the successes and challenges of the HRH program, the report recommends that future investments in health professional education be designed within a more comprehensive approach to human resources for health and institutional capacity building, which would strengthen the health system to meet both HIV-specific and more general health needs. The recommendations offer an aspirational framework to reimagine how partnerships are formed, how investments are made, and how the effects of those investments are documented.

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