National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda (2020-2025)

1.1 Context and background................................................................................................................................................. 13

1.2 Purpose. ............................................................................................................................................................................. 14 2 OVERVIEW OF THE NCD BURDEN AND RESPONSE ........................................................................................... 16

2.1 Global and regional burden of NCDs. ........................................................................................................................... 16

2.2 The national burden of NCDs in Rwanda..................................................................................................................... 18

2.3 Socioeconomic impact of NCDs in Rwanda............................................................................................................... 30

2.4 Health system organisation and coverage of NCD health services. ...................................................................... 32

2.5 Key issues facing NCD programming and governance in Rwanda . ...................................................................... 35

2.6 Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis for the prevention and control of NCDs. ....... 36 3 METHODOLOGY................................................................................................................................................... 38 4 GOAL AND STRATEGIC OBJECTIVES . ................................................................................................................ 39 Vision......................................................................................................................................................................................... 39 Mission...................................................................................................................................................................................... 39 Goal ........................................................................................................................................................................................... 39 Strategic objective 1. .............................................................................................................................................................. 40 Strategic objective 2. .............................................................................................................................................................. 44 Strategic objective 3. .............................................................................................................................................................. 48 Strategic objective 4. .............................................................................................................................................................. 49 5 IMPLEMENTATION, MONITORING AND EVALUATION FRAMEWORK............................................................... 50 6 NATIONAL COSTED ACTION PLAN FOR THE PREVENTION AND CONTROL OF NCDS............................ 78

6.1 Introduction....................................................................................................................................................................... 78

6.2 Methodology of the OneHealth Tool............................................................................................................................. 80

6.3 Results............................................................................................................................................................................... 85

6.4 Financing gap in NCD programming............................................................................................................................ 95

6.5 Conclusion. ....................................................................................................................................................................... 97 7 REFERENCES. ....................................................................................................................................................... 98 8 ANNEXES. ........................................................................................................................................................... 102

8.1 Programmes.................................................................................................................................................................... 102

8.2 Intervention coverage. ................................................................................................................................................... 104 EXECUTIVE SUMMARY Guiding Rwanda’s response to addressing non-communicable diseases (NCDs), this National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases covers a five-year period from July 2020 to June 2025. Incorporating key learnings from Rwanda’s first Non- Communicable Diseases and Injuries National Strategic Plan 2014-2019, this is also inspired by, and aligned with, key national policies and plans. This document combines Rwanda’s national strategy for NCDs, together with a costed action plan. It lists the critical stakeholders involved in the prevention and control of NCDs in Rwanda and details the agreed operational priority interventions and their targets. This strategy envisions a Rwanda free from the avoidable burden of NCDs, including injuries and disabilities. In Rwanda, as elsewhere around the world, the burden of NCDs is increasing. World Health Organization (WHO) estimates from 2016 show that NCDs, injuries and disabilities, accounted for 58 percent of total annual mortality in Rwanda [8]. Cardiovascular diseases, injuries, cancers, chronic respiratory diseases and diabetes are the biggest killers; these same diseases will be the focus of this five-year plan. Rates of NCDs are likely to be much higher than national statistics show, as many are not screened and go undiagnosed. Three key domains are presented in this strategic plan to steer actions in tackling NCDs. The first, community action and engagement, is key to changing behaviours and increasing early detection. The second focuses on the prevention and control of NCD risk factors, like unhealthy diets, the harmful use of alcohol, and tobacco smoking. Quality NCD diagnosis and treatment services at all levels of care is the final domain. Enhanced national multisectoral collaboration is a common theme throughout the national strategy. It is only through the involvement of all stakeholders that this plan will be successful in its mission to alleviate the economic, social and medical burden of NCDs in Rwanda, to reduce morbidity and premature mortality, improve functionality and ensure a healthier population. The overarching goal of this plan is to reduce premature mortality from NCDs by 25 percent, by 2025. The actions that need to be taken to achieve this are organised in four strategic objectives: National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 7 1 priority Preventing NCDs through health promotion and areas reduction of risk factors 1. Awareness-raising / education to reduce exposure to modifiable NCDs risk factors. 2. Immunisation and early treatment of infections leading to NCDs. 3. Establish and strengthen the implementation of policies and regulations addressing NCD risk factors. 4. Improve road safety for the prevention of injuries and disabilities. 5. Deliver on communication plan to accompany the national strategy and costed action plan. 2 priority Strengthening health systems for quality NCD areas early detection, care and treatment at all levels 1. Human resources development for NCD early detection, care and treatment. 2. NCD service delivery. 3. Strengthen the supply chain of NCDs medications, laboratory commodities, and technologies/medical equipment. 4. Ensure continuous research and development to establish and advance various NCD treatment guidelines and protocols. 5. Financing of NCD prevention and control. 6. Enhance patient psychosocial and resource support programmes. 7. Establish policies and regulations to ensure continued access to NCD services during emergencies such as pandemics or epidemics (e.g. COVID-19). 8. Establish specialised NCD, including injuries and disabilities, diagnostic and treatment centres. 3 Strengthening disease surveillance and research, priority areas alongside robust monitoring and evaluation, for evidence-based intervention 1. Strengthen disease surveillance and M&E systems. 2. Enhance research for evidence-based interventions. 4 Strengthening intersectoral coordination, priority areas advocacy and resource mobilisation for the prevention and control of NCDs 1. Establish national mechanisms to coordinate the prevention and control of NCDs. 2. Enhance international, national and decentralised coordination mechanisms for prevention and control of NCDs. 8 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Within each of these objectives are expected outputs, including indicators and measures to be tracked. As is commensurate with the scale and importance of the challenge, these are ambitious. For example, while Rwanda has a relatively low prevalence of tobacco smoking, more efforts will be put to further reduce prevalence of smoking from 13 percent, down to 10 percent of the population, with greater focus on persons over 15-years-old. Similarly, a national alcohol policy and action plan will be developed, allowing better understanding of the burden of the harmful use of alcohol in Rwanda and reducing its prevalence. Measures will be taken to halt the rise of diabetes and obesity, keeping obesity prevalence at 2.8 percent. Efforts over the next five years will ensure quality NCD services reaching at least 50 percent of the people who need them, with continuous availability of affordable NCD supplies and technologies. Achieving this will require a shift in financing. National budget allocation, although increased, is limited and not proportional with the burden faced. This plan details alternative approaches. Every Rwandan Franc invested in NCD care brings cost savings, direct and indirect, many times higher. The costed action plan outlines the resources needed to achieve the defined objectives, and a total budget of RWF 358.1 billion (USD 376.2 million) is required for the period of the plan (2021-2025). To fund the activities in the strategy, there is need to set priorities. This has to happen within budget allocations across government sectors, by developing a list of cost- effective priority activities within this strategy, as well as bringing in new funders and funding innovations. This will require close collaboration among different players including government departments, the private sector, local communities, and development partners. While this strategic document and costed action plan is meant to provide guidance, clarity of purpose, and national alignment as we respond to NCDs, it does not imply that the strategy is frozen for the next five years. As a result, we expect that this strategy will evolve during its five-year lifespan, as new facts and evidence come to light, and new contexts emerge. LIST OF ACRONYMS AND ABBREVIATIONS AT Assistive Technology M&E Monitoring and Evaluation CBHIs Community-Based Health Insurers MRI Magnetic Resonance Imaging CHUB University Teaching Hospital of Butare MoH Ministry of Health CHUK University Teaching Hospital of Kigali NCAP National Costed Action Plan CHWs Community Health Workers NCD Non-Communicable Disease CoD Cause of Death NST National Strategy for Transformation COPD Chronic Obstructive Pulmonary Diseases OHT One Health Tool CRDs Chronic Respiratory Diseases OP Out-Patient CSOs Civil Society Organisations OOP Out-of-pocket CT or CAT Computed Tomography PEN Package of Essential NCD Services CVDs Cardiovascular Diseases PHC Primary Health Care CVRs Civil Registration and Vital Statistics RBC Rwanda Biomedical Centre DALYs Disability-Adjusted Life Years RHD Rheumatic valvular heart disease DM Diabetes Mellitus RSP Rehabilitation Strategic Plan Rwanda Social Security Board - Community-Based GBD Global Burden of Disease RSSB-CBHI Health Insurance GDP Gross Domestic Product RWF Rwandan Franc HIS Health Information systems SDGs Sustainable Development Goals HMIS Health Management Information System SWOT Strengths-Weaknesses-Opportunities-Threats HPV Human Papilloma Virus TB Tuberculosis HRH Human Resources for Health THE Total Health Expenditure HRTT Health Resource Tracking Tool TWGs Technical Working Groups HSSP4 Fourth Health Sector Strategic Plan UHC Universal Health Coverage HTN Hypertension USD United States Dollar IARC International Agency for Research on Cancer VA Verbal Autopsies International Classification of Functioning, ICF WHO World Health Organisation Disability and Health IHME Institute for Health Metrics and Evaluation WHO FCTC WHO Framework Convention on Tobacco Control IP In-Patient YLL Years of Life Lost LMICs Low- and Middle-Income Countries 10 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 LIST OF PARTNERS ACS American Cancer Society AFCRN African Network of Cancer Registries CDC Centre for Disease Control CHAI Clinton Health Access Initiative DHS Institute Demographic and Health Survey Institute Einstein-Rwanda Research and Capacity Building Programme DNCD The Defeat-NCD Partnership ENABEL Belgian Development Agency FDA Food and Drugs Authority GAVI Gavi, the Vaccine Alliance HEC Higher Education Council HRHS Human Resource for Health Services HRHS Human Resource for Health Services IARC International Agency for Research on Cancer JADF Joint Action Development Forum MIBIICT Ministry of ICT and Innovation MIFOTRA Ministry of Public Service and Labour MINAFET Ministry of Foreign Affairs MINAGRI Ministry of Agriculture and Animal Resources MINALOC Ministry of Local Government MINECOFIN Ministry of Finance and Economic Planning MINEDUC Ministry of Education MINICOM Ministry of Trade and Industry MINICOM Ministry of Trade and Industry MINIFRA Ministry of Infrastructure MINISPORTS Ministry of Sports MoA Ministry of Agriculture MoH Ministry of Health MoYC / MYCULTURE Ministry of Youth and Culture (MoYC or MYCULTURE) National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 11 NCDA NCD Alliance PIH Partners In Health RBC Rwanda Biomedical Centre RDA Rwanda Diabetes Association REB Rwanda Education Board RFDA Rwanda Food and Drugs Authority RISA Rwanda Information Society Authority RMS Ltd Rwanda Medical Supply Limited RNP Rwanda National Police RRA Rwanda Revenue Authority RRC Rwanda Red Cross RURA Rwanda Utilities Regulatory Authority SFH Society for Family Health Team Heart TT1 Team Type 1 UNICEF United Nations Children’s Fund UR University of Rwanda WDF World Diabetes Foundation WHO World Health Organization 12 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 1 INTRODUCTION

1.1 Context and background This National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda 2020-2025 will guide the national response to NCDs in Rwanda over a period of five years. This follows the first Rwanda Non-communicable Diseases and Injuries National Strategic Plan 2014- 2019. This 2020-2025 strategy was developed incorporating lessons learnt in the implementation of the 2014-2019 plan, together with the Global NCD Action Plan, the Fourth Health Sector Strategic Plan (HSSP4), and National Strategy for Transformation (NST1). This national strategy will fulfil Rwanda’s commitment to delivering Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages, and, more specifically, target 3.4: By 2030, reduce by one-third premature mortality from NCDs. WHO defines premature mortality, in relation to NCDs and the SDGs, as preventable deaths of people aged 30 to 70 years old. This strategy responds to other voluntary, global NCD targets, accelerating actions taken to address major risk factors, as well as the availability of drugs and equipment to manage major NCDs. This strategy also provides details on realising a healthy, productive population, in line with ‘The Rwanda We Want: Towards Vision 2050’. HSSP4 anticipated the epidemiological transition of the country, the increase in population and life expectancy, and the expected increase in health needs of the elderly. The plan detailed the correlation with NCDs and the subsequent increase in prevalence. HSSP4 also predicted a decrease in external financial inflows. This national strategy is therefore critical to address and highlight the most efficient and effective operational strategies to tackle NCDs, affordably and sustainably. The global COVID-19 pandemic, with its devastating effects on economies, on health systems in general, and on patients with NCDs in particular, emphasises the imperativeness of this plan. Tackling NCDs is important to decrease mortality and the risk of severity among COVID-19 cases. This strategic document includes a costed action plan for five years, July 2020 to June 2025; taken together they are an operational plan that translates the agreed priorities into detailed service packages, to be implemented by the various actors involved in the prevention and control of NCDs in Rwanda. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 13

1.2 Purpose The overarching goal of the national strategy and costed action plan is to reduce premature mortality due to NCDs by 25 percent, by 2025. It aims to achieve this by improving universal accessibility, in geographical and financial terms, of equitable, affordable, and quality NCD services (preventative, curative, rehabilitative and promotional) for all in Rwanda. The strategy and costed action plan focuses on the major four killers, namely cardiovascular diseases (CVDs), diabetes, chronic respiratory diseases (CRDs) and cancer, in addition to injuries and disabilities. The strategy has three key domains to guide action on tackling NCDs in Rwanda: • Community awareness and engagement for behavioural change and early detection • Prevention and control of NCD risk factors • Quality NCD diagnosis and treatment services at all levels of care Implementation of these action domains relies on the following guiding principles and approaches: A multisectoral approach The nature of NCDs, and various social determinants of health and risk factors, requires the involvement of both health and non-health sectors in prevention and control measures. Mechanisms to ensure coordinated multi-stakeholder engagement and multisectoral action for health both, within government and by non-government actors, are being developed. A National Multisectoral Steering Committee, supervising the development and implementation of the strategy and costed action plan will convene regularly. Technical Working Groups (TWGs) responsible for the development, implementation, monitoring and evaluation (M&E) of the strategy and costed action plan will convene quarterly. A life-course approach Rwanda’s population is quite young and growing. And with life expectancy increasing, it is also an aging population. With globalisation and 21st-century influences affecting lifestyles and local practices, prevention and care of NCDs needs to span all age demographics. Interventions to limit NCDs should begin early in life to have maximum impact. From conception, through early childhood, and continuing over the course of life, addressing NCDs relies on increasing general knowledge and empowering people to make healthy choices. Specific attention needs to be made in caring for senior citizens. 14 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 A human rights approach Article 41 of the Rwandan Constitution amended in 2015 states: “All citizens have rights and duties relating to health. The State has the duty of mobilising the population for activities aimed at promoting good health and to assist in the implementation of these activities. All citizens have the right of equal access to public services in accordance with their competence and abilities.” An equity-based approach The disparity in occurrence of NCDs is due to unequal distribution of social determinants of health. Action on the determinants of health, both for vulnerable groups and the entire population, is essential to create inclusive, equitable, economically productive and healthy communities. The COVID-19 pandemic has further exposed vulnerabilities and contributed to increased suffering of NCD patients globally, confirming that the global surge of premature mortality caused by NCDs shares many similarities with, and requires the same level of preparedness and response for, pandemics of infectious diseases. All activities included within this strategy will be disability inclusive. Empowerment of individuals and communities Individual and community participation should be geared towards helping informed decision making, and leading activities related to the prevention and control of NCDs. Individuals and communities will participate in advocacy, policy development, planning, legislation, service provision, research, and M&E. An evidence-based approach NCD-related policies, guidelines and interventions will be based upon evidence, with an emphasis on scientific and clinical research. Integration Addressing NCDs must adopt an expansive, integrated, health system approach, rather than looking at individual programmes in isolation. All interventions to prevent, control and manage NCDs need to span service delivery, with a focus on primary health care and community services, and include long-term care services. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 15 2 OVERVIEW OF THE NCD BURDEN AND RESPONSE

2.1 Global and regional burden of NCDs NCDs, also known as chronic diseases, are the world’s leading cause of death, morbidity, and disability. NCDs result from a combination of behavioural, physiological, environmental, and genetic factors. NCDs are the main cause of mortality globally, accounting for more than 70 percent of deaths. Close to 85% of these deaths occur in low- and middle-income countries (LMICs), and within this, 82% of these deaths are due to four primary NCDs: CVDs (17.5 million deaths annually), cancers (8.2 million), CRDs (4.0 million) and diabetes (1.5 million) [1]. Most premature mortalities due to NCDs can be avoided with well-established interventions to target common, modifiable risk factors. These behaviourally modifiable risk factors include physical inactivity, harmful use of alcohol, tobacco use and unhealthy diets. Metabolic risk factors include being overweight and obesity, raised blood pressure, raised blood glucose and abnormal blood lipids levels. Oral, ear and eye health, mental health, and injuries from road accidents and other physical harm, are additional NCDs prioritised in many countries including Rwanda. The burden in Sub-Saharan Africa is no different. An in-depth analysis of the burden of NCDs in sub- Saharan Africa shows that, in 2017, the leading causes were CVDs (22.9 million disability-adjusted life years or DALYs), neoplasms (16.9 million), mental disorders (13.6 million), and diabetes (10.4 million), in line with the leading causes of mortality due to NCDs [2]. The burden of NCDs is not only epidemiological, but comes at a huge cost for individuals, households and entire societies. For chronic cases, the need for life-long treatment means escalated health care costs and loss of productivity, especially in undiagnosed or untreated cases. NCDs are preventable, but multisectoral efforts are required from all stakeholders to address underlying socioeconomic determinants, behavioural, environmental and other risk factors. Such efforts need to be based 16 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 on strategic, long-term, well-executed action plans, as well as population-based cost-effective interventions, to reduce the impact of NCDs on society. NCD-related high mortality can be reversed through early detection and quality care. For example, a 2017 report on monitoring NCD commitments in Europe shows a rapid decline in premature deaths related to NCDs. The region is likely to achieve and exceed SDG target 3.4 [3]. WHO estimates that up to 80 percent of premature heart disease, stroke and diabetes could be prevented with the right interventions [4]. People with NCDs often suffer from two or more conditions, such as diabetes and hypertension (HTN), which are closely linked. NCDs are also interconnected to, and interact with, communicable diseases. Health systems must therefore increasingly manage patients living with NCDs as well as communicable diseases. For example, antiretroviral drugs allow people with HIV to live longer, putting them at risk of developing NCDs. There is also evidence of a relationship between HIV/AIDS and CVDs, diabetes and some cancers; and between diabetes and tuberculosis (TB). Infectious respiratory diseases like TB weaken the lungs and expose patients to a greater risk of developing CRDs like chronic obstructive pulmonary disease (COPD) and asthma [5]. Figure 1: Interaction between TB, malaria and HIV/AIDS, risk factors or disease precursors, and NCDs Tuberculosis Malaria HIV High BP Nutrition* Alcohol Tobacco Urban/indoor air pollution Socio-environmentalˆ Unsafe sex Physical inactivity Chronic kidney disease COPD Diabetes Cerebrovascular disease Ischaemic heart disease * Encompasses underweight, overweight/obesity, ˆConditions associated with informality: low fruit/vegetable consumption, high glucose intake overcrowding, unsafe water and sanitation National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 17

2.2 The national burden of NCDs in Rwanda

2.2.1 Demographics and epidemiology of NCDs in Rwanda Rwanda’s population stands at 12.4 million people, as of 2019, with an annual growth rate of about 2.1 percent. The population pyramid shows a relatively young population, expected to record a marginal shift by 2030 [6]. The total fertility rate declined from 5.7 to 4.0 children per woman between the years 2000 and 2018. Over the same period, average life expectancy at birth increased from 47 years to 69 years, denoting an ageing population. This indicates increased risk of NCDs. The burden of NCDs in Rwanda has increased tremendously over the years. In 2018, the Institute for Health Metrics and Evaluation (IHME) noted that NCDs are significant contributors to health loss in Rwanda, accounting for 35 percent of DALYs in 2016, up from 16 percent in 1990 [7]. WHO estimates from 2016 show that NCDs accounted for 44 percent of total annual mortality in Rwanda, with CVDs and injuries the single largest shares of NCD-related mortality (both 14%), followed by cancers (13%), CRDs (3%), diabetes (2%) and other NCDs (13%) [8]. Figure 2: Proportional mortality (% of total deaths, all ages) in 2016 (WHO) 13% Other NCDs 42% 14% Communicable Injuries Maternal, Perinatal and Nutritional conditions 2% Diabetes Chronic 3% respiratory disease 13% Cancer 14% Cardiovascular diseases There are still gaps in mortality data and the Civil Registration and Vital Statistics (CVRS) of Rwanda faces challenges in recording deaths occurring outside of health facilities, which are usually neither notified nor registered. To address this, Rwanda initiated the registration and reporting of probable cause of death (CoD) when deaths occur outside of medical facilities. In the absence of trained physicians able to complete a CoD medical certificate, this is instead done through verbal autopsies (VA). 18 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 VA data in pilot districts shows that NCDs are the most common CoD, resulting in more deaths than all other CoDs combined. VA data also shows higher rates of deaths related to NCDs when compared to data provided by health facilities. People with NCDs may be more likely to die in their communities, rather than in a health facility, when compared to patients with other conditions. There is a tendency for people with acute illnesses to immediately consult health facilities for treatment, whereas patients with NCDs may tolerate the disease for many years without treatment. Additionally, some significant risk factors do not cause recognisable symptoms until the disease is extremely advanced. Higher rates of NCD deaths in the community also show that, although Rwanda has made significant efforts to fight communicable diseases, the capacity to diagnose and manage NCDs may have not improved at the same speed. Therefore, some people with NCDs may go undiagnosed and die from NCDs before they reach health facilities. For example, previous studies have shown that half of patients with diabetes are undiagnosed [9]. Figure 3: Distribution of adult deaths by broad Global Burden of Disease (GBD) category from VA data, before and after redistribution (adjusting data to better represent the whole population), 2017/18 Before Redistribution After Redistribution 14% 22% Injuries Undertermined 28% CDs 48% 9% NCDs Injuries 58% 21% NCDs CDs National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 19 Figure 4: Comparison of leading causes of adult deaths from VA data and GBD estimates 14% 12% 10% 8% 6% 4% 2% 0% Stroke Malaria Road Traffic Accident Maternal Other Cancers Ischemic Heart Disease Cirrhosis Diabetes TB Falls Leukaemia Suicide Pneumonia CRDs Renal Failure Diarrhea HIV/AIDs Other Injuries Other Infectious Diseases Proportion of deaths (%)

2.2.2 Burden of the most common NCDs inGBD HMIS-VA (2017-2019) Rwanda (2017) Cardiovascular Diseases (CVDs) There are currently no nationwide studies on CVDs and it is therefore difficult to tell their actual prevalence. Below is a summary from available literature in Rwanda. STROKE: A multicentre study on strokes (haemorrhagic and ischemic) showed that the burden of strokes constituted 2,100 per 100,000 population in Rwanda. Among these, 22% were not aware of their previous health status, and 53.5 percent of hypertensive patients were not on treatment at the time of the event [10]. HEART FAILURE: A retrospective study to determine the etiology of heart failure in Rwanda shows that congenital heart diseases (52%) and rheumatic heart disease (36%) were the most common causes of heart failure among children. For adults, cardiomyopathy (40%), rheumatic heart disease (27%) and hypertensive heart disease (13%) were most common. 20 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 40% of adults present for the first time with heart failure class III to IV (late-stage, requiring surgical intervention) [11]. RHEUMATIC VALVULAR HEART DISEASE (RHD): A few small-scale published studies for rheumatic fever (RF) and RHD, conducted among Rwandan school children in 2017, showed that RHD prevalence was 6.8 per 1,000 children examined [12]. Chronic Respiratory Diseases (CRDs) CRDs include bronchial asthma, chronic pulmonary diseases such as chronic obstructive pulmonary diseases (COPD), occupational lung diseases and chronic interstitial lung diseases. In 2011, a cross-sectional study conducted among urban and rural communities in Rwanda showed that: the prevalence of asthma and COPD were 8.9% and 4.5% respectively among participants, and chronic bronchitis had a prevalence of 10.7% . [13] Household air pollution from solid fuels is considered to be one of the three risk factors that account for the highest disease burden in Rwanda. The other two are being underweight in childhood and alcohol use. A WHO risk factor survey in 2014 shows that self-reported asthma cases accounted for 1.1 percent of the overall population, with greater prevalence in women [14]. This percentage is much lower than the cross-sectional study referred to above. The difference may be explained by the self-reporting methodology of the WHO survey, which excluded undiagnosed cases. Based on an average of 1.1 percent prevalence of asthma, it is estimated that 141,900 people are living with asthma in the country. Data from Rwanda’s Health Management Information System (HMIS) shows that around 10,741 persons with asthma were enrolled in care in 2019. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 21 Most asthma patients in Rwanda are therefore not diagnosed, and consequently not receiving treatment. The current coverage rate is around 7.5 percent. The aim is to increase this to 50 percent by 2025. Diabetes mellitus (DM) The prevalence of DM in Rwanda is estimated at between 3.0 and 3.5 percent. A 2012-2013 WHO STEPwise approach to surveillance (STEPS) survey [14] indicated that age-adjusted diabetes prevalence is 3.1 percent (for populations aged 15-64 years) and 4.3 percent (for populations aged 20-79 years). The WHO STEPwise approach to surveillance (STEPS) involves three different levels or ‘steps’ of risk factor assessment Based on calculations using an average DM prevalence of 3.2 percent, it is estimated that 396,800 people are living with diabetes in the country. HMIS data shows that around 15,763 persons with diabetes were enrolled in care in 2019. Around 2,000 of them have type 1 diabetes. A World Development Indicators report noted: a sharp rise (167.5%) in diabetes cases between 2010 and 2017 among 20-79 year-olds in Rwanda [15]. WHO indicates that one in every 30 Rwandans has diabetes[8], and the Rwanda Diabetes Association reports that 1,918 people in the country die from diabetes and high blood glucose every year [27]. It is projected that the DM prevalence will rise significantly in coming years, posing an increased burden on the health system. Some of the factors behind the increasing burden of the disease include improved detection and diagnosis, urbanisation and changes in lifestyle. Low health literacy in the country also means that the majority of the population cannot recognise the signs and symptoms of DM and are likely to present late with the illness, leading to potential complications. A shortage of skilled health workers, especially at primary care level, where the majority of Rwandans seek care, also poses a significant challenge in diabetes control and prevention. Considering all the above, most diabetes patients in Rwanda are not diagnosed and accordingly are not being treated. The current coverage rate is around 4 percent and the aim is to increase this to 50 percent by 2025. 22 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Figure 5: Prevalence of diabetes, as presented in Rwanda’s STEPS 2012-2013 [14] 5 4.9 5 4 3.6 3.4 3.5 3.3 3.3 3 2.7 2.3 2.3 2 1 0 15-24 24-34 35-44 45-54 55-64 Age group (years) Male Female Cancers Global estimates from the Global Cancer Observatory are that there were about 10,704 new cancer cases and 7,662 deaths in 2018 [16]. According to the International Agency for Research on Cancer (IARC), without effective intervention, there will be about 13,863 new cancer cases every year (7,944 women and 5919 men) in 2025. Annual mortality from the disease would be 10,112 (4,479 men and 5,633 women) by 2025. The age-standardised rate for cancer incidence per 100,000 among men is 130.9 and 144.8 in women in 2018. About 14 percent of women are at risk of developing cancer before the age of 75 years, compared to men at 12.7 percent. Like other NCDs, the cancer burden in Rwanda is increasing. Data covering the 2007-2018 period from a newly established cancer registry in Rwanda provides the data included below. In men, prostate is the most commonly diagnosed malignancy with 1,019 cases, followed by stomach (837 cases) and lymphoma (804 cases). In women, cervix and breast are the most commonly diagnosed malignancy with 2,440 and 2,382 cases respectively, followed by stomach (863 cases). A comparison of data from the Rwanda Cancer Registry with IARC data strongly suggests that the majority of cancer cases in the country are never National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 23 diagnosed or treated. For example, WHO’s Global Cancer Observatory estimates breast cancer cases for Rwanda as 1,131 new cases annually, whereas annual cases recorded in the national registry are just 217. This suggests that only 20 percent of new cases are being diagnosed. Figure 6: Cancer cases 2007-2018 in Rwanda (National Cancer Registry) 2933 3000 2697 2500 2241 2250 2300 2155 2000 1828 1500 999 1000 768 826 634 629 500 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Figure 7: Top 10 cancers in Rwanda 2017-2018 (National Cancer Registry) Corpus / Oesophagus Uterus NOS Lung. Trachea Mouth / bronchus pharynx Brain / nervous Liver system Mouth / Ovary / pharynx adnexa Colon. Rectum. Anus Leukemia Colon. Rectum. Leukemia Anus Liver Lymphoma Lymphoma Stomach Stomach Breast Prostate Cervix 0 200 400 600 800 1000 1200 0 500 1000 1500 2000 2500 24 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Injuries and disabilities The prevalence of injuries and disabilities is estimated at 5.2 percent of the population [28]. A small-scale study in two hospitals reported a morbidity of 14 percent and a mortality of 10 percent due to interpersonal violence [17]. In a nationwide study, the main drivers of injuries and disabilities include falls (45%), animal attack (16%) , weapons (11%) , road accidents (10%), burns (9% and work/home injuries (9%) [18]. Global Burden of Disease (GBD) data from 2010 estimated that injuries and disabilities, comprising road accidents, interpersonal violence, self-harm and falls, constituted the third highest burden of disease and accounted for 7.2 percent of total years of life lost (YLL) in Rwanda [19]. Rehabilitation services In response to WHO’s Rehabilitation 2030 initiative, Rwanda has started customising areas of action to its context through the development of a comprehensive Rehabilitation Strategic Plan (RSP). The RSP is organised around four key phases with a pre-set timeline for each phase: 1. Situation assessment 2. Development of plan 3. Establishment of M&E and review processes 4. Implementation of strategic plan The RSP will be defined in collaboration with rehabilitation stakeholders focusing on health system building blocks and using WHO guidelines as follows: • Leadership and governance: multisectoral coordination and support for rehabilitation at all levels of care, with effective guiding policy and legislation. An operational rehabilitation TWG will support the implementation of this strategy. • Financing: advocacy for insurance coverage providers to increase scope of rehabilitation service coverage, and explore sources of funding to subsidise such services. • Human resources: develop a multidisciplinary rehabilitation workforce at all levels of care, and initiate training for specialised services (e.g. speech therapy). • Service delivery: ensure quality, equitable and accessible rehabilitation service delivery. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 25 • Assistive technology (AT): include AT and essential items required to fabricate local AT on the list of essential devices, as outlined in Rwanda’s 2019 AT needs-assessment and other reports. • Infrastructure and medication: improve rehabilitation infrastructure, as well as the availability of raw materials, to ensure the smooth functioning of rehabilitation services. • Information and research: enhance research and health information systems (HIS) by including system-level rehabilitation data and information on functionality, using the International Classification of Functioning, Disability and Health (ICF). • Emergency preparedness: define the modalities of coping with eventual emergencies and mitigating their impacts on beneficiaries, and advocate for the inclusion of rehabilitation into Rwanda’s disaster management plan.

2.2.3 Risk factors for NCDs in Rwanda and the current implementation status of the control measures The Rwanda Ministry of Health (MoH) Non-Communicable Diseases Risk Factors Report from 2012 shows that the main risk factors are the harmful use of alcohol and an unhealthy diet, followed by tobacco use. Physical inactivity and obesity were not presented as major risk factors in Rwanda in the report. However, cases of obesity are increasing. Hypertension A countrywide population-based survey showed HTN prevalence at 15.9% (16.8% for males and 15% for females) [14]. Only 22 percent were diagnosed. Another study shows HTN prevalence of 36 percent in adults aged 27 to 67 years [20]. Using the statistic of an average 15.9 percent prevalence of HTN, it is estimated that 1,188,142 people between the age of 15 and 64 are living with HTN in Rwanda. HMIS data from 2019 shows that around 63,692 persons with HTN enrolled in care. Most patients with HTN in Rwanda are not diagnosed and therefore not receiving treatment. The aim is to increase the coverage rate of around 5.4 percent to 20 percent by the year 2025. 26 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Alcohol consumption and control In Rwanda, the overall prevalence of alcohol drinkers is estimated at 41.2 percent (males 52%, females 31.4%). Alcohol consumption is highest in semi-urban areas (44.7%), followed by in rural residences (43.1%) and urban residences (29%) [6]. Locally produced alcohol is affordable and accessible to a large majority of the Rwandan population. Despite high taxation on commercially produced alcoholic drinks, the population’s large-scale consumption of locally brewed alcohol poses several challenges for alcohol control in Rwanda. There is a need to increase awareness in the general population on the harmful use of alcohol, as there is currently no significant media outreach focused on raising awareness of alcohol abuse. Unhealthy diet Overall fruit and vegetable consumption in Rwanda is very low. In Rwanda’s STEPS 2012-2013, 99.6% of the population consumed less than five servings of fruit per day and 99.3 % consumed less than five servings of vegetables per day [14]. It is also important to highlight the low diet diversity found generally in the diet of the Rwandan population. A national Nutrition, Market and Gender survey by the Rwanda Agriculture Board in 2015 found that women of reproductive age have an unbalanced diet. A food consumption survey using a 24-hour recall method revealed that there were few consumers (≤5%) of coloured vegetables (rich in Vitamin A), eggs, fish, and meat. It also found that fat consumption was insufficient, and that their diet was largely composed of carbohydrates [30]. The consumption of salt in Rwanda is not documented. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 27 Tobacco use In Rwanda, adult tobacco smoking prevalence stands at 12.8 percent with variations in age and sex. Male smokers accounted for 19.1%, while females accounted for 7.1% . Smoking prevalence also varied by residence with the highest prevalence reported in rural areas (13.5%), followed by semi-urban (12.0%) and urban areas (9.7%) [14]. Currently, the Government of Rwanda, in collaboration with several multisector stakeholders, is implementing and enforcing the WHO Framework Convention on Tobacco Control (FCTC). This includes different tobacco laws and orders, focused on increasing tobacco taxes; inciting business owners to comply with laws and regulations on tobacco control; reducing, and possibly eliminating, exposure to second- hand smoke; promoting smoking cessation and preventing smoking initiation; and preventing people under 18 years-old from any contact with tobacco products. Insufficient physical activity In Rwanda, 61.5% of the population have high levels of physical activity; 25.2% moderate levels and 13.3% have low levels of physical activity. Younger people were more likely to report high levels of physical activity than older people. STEPS 2012-2013 stated that males were more physically active than females (65.8% vs. 57.6%) [14]. Similarly, people residing in semi-urban and rural areas have higher levels of physical activity than urban dwellers (semi-urban 68.2%, rural 64.4% and urban 42.8%). There are also regional variations in physical activity: Western (67.8%), Southern (65%), Eastern (64.3%), Northern Province (54.6%) and Central Kigali (46.7%) [14]. In 2014, MoH, in collaboration with the Ministry of Sports and Ministry of Local Government, introduced a ‘Sports for All’ initiative across Rwanda. For 28 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 example, in May 2016, the City of Kigali, Rwanda’s capital, launched a ‘Car Free Day’, aimed at encouraging people to engage in regular physical activities to prevent NCDs. It started as a once-a-month idea, and now takes place twice a month in Kigali and has been extended to other districts. In addition to promoting physical activity, it also serves as a platform for NCD awareness and screening. Since the initiative started in 2016, 48,782 people have been screened for NCDs. Among those screened, 23.7 percent were found to have high blood pressure, 9.4 percent had high blood sugar and 11 percent were obese. This reflects higher prevalence rates in Kigali, supporting WHO’s STEPS results. Overweight and obesity STEPS 2012-2013 found that 2.8 percent of Rwanda’s population are obese, 14.3 percent are overweight and 7.8 percent are underweight. Obesity is most prevalent in the age group 35-54 and among females (4.7%). Furthermore, the prevalence of obesity is more predominant in urban areas (10.2%), and Kigali specifically (7.7%). Northern Province has the lowest prevalence of obesity (1.8%) [14]. A comparison of Rwanda’s demographic and health surveys from 2000 and 2015 show the prevalence of being overweight or obesity in women of reproductive age has doubled within 10 years and is of public health concern, especially in urban areas [24, 25]. 36.8 percent of women were overweight or obese in urban areas, compared to 16.8% in rural areas [25]. Environment, occupation and nutrition Environmental, occupational and nutritional risk factors like indoor pollution, agrochemicals, aflatoxins and asbestos exposure have been recognised regionally and internationally as risk factors contributing to increased NCD- related morbidity and mortality. More research into this burden for Rwanda will be generated over the course of the next five years. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 29

2.3 Socioeconomic impact of NCDs in Rwanda The negative impacts of NCDs affect health systems, individuals, families, businesses, and governments. Global economic analysis suggests that: a 10% rise in NCDs is associated with 0.5% lower rates of annual economic growth [21]. There are currently no reliable socioeconomic impact studies on NCDs in Rwanda. The prevention and control of NCDs is globally prioritised in the SDGs but remains grossly underfunded at all levels. NCDs receive less than 3 percent of global development assistance [22]. In Rwanda, total expenditure on NCDs is not captured in detail within the Health Resource Tracking Tool (HRTT), as there is no itemised expenditure by NCD cluster. This makes it difficult to understand which of the NCDs are being prioritised and which are not. Nonetheless, and despite the rising burden of NCDs, budget allocations remain very low. In fiscal year (FY) 2015-16, approximately 0.8 to 2 percent of the health budget was allocated to NCDs, compared with 57 percent for HIV/AIDS and other blood-borne diseases [35]. Budget allocation to NCDs increased in FY2016-17, but this increase was very limited vis-à-vis the disease burden. Less than 1.7% of the 186 billion Rwandan Francs (RWF) spent on disease prevention and control programmes was spent on NCD control and prevention, according to HRTT from July 2020. Out-of-pocket (OOP) expenditure analysis in Rwanda using HRTT data shows low commitments to NCDs. Analysis done in 2014 studied expenditures relating to medical consultations and exams, hospitalisation, asthma drugs, astringents (e.g. iodine), heart disease medicine, diabetes drugs, hearing aids/prosthetic limbs/disability aids, and high/low blood pressure drugs. In this analysis, more expensive NCD services like cancer treatment and care, heart and neurologic surgeries and palliative care costs were not considered. These need to be included in order to give a true picture of NCD treatment and care costs. The analysis showed low NCD expenditure on heart medicine (3%), asthma and DM (1% each) , and HTN (2%). Consultations (37%) and hospitalisation (17%) are the main drivers of OOP spending and could potentially be traced back to NCDs. 30 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 As Rwanda makes progress to universal health coverage (UHC) and moves closer to realising the SDGs, it needs to mobilise adequate resources to pay for necessary NCD services and reduce the impact on households. Reports from Rwanda’s Social Security Board states that members of community-based health insurers (CBHIs) are low-income earners who cannot afford to pay even one percent of the cost of their medication [29]. More information is required around public budgeting for NCD medicines and the extent to which budgets have facilitated widespread access to essential generic medicines. An emerging gap in NCD programming in Rwanda is the levels of OOP spending on these conditions and their consequences on household economies. Rwanda’s Fifth Integrated Household Living Survey (EICV 5) covering 2016-2017 showed that 19.3% of households reported a financial shock over a period of 12 months, due to serious illness or accident among household members. Knowing that NCDs are the most common cause of morbidity, in addition to the high cost of treatment and care, it can be assumed that a high percentage of these household shocks can be attributed to NCDs [26]. One Rwanda study highlights the annual cost per patient for some NCDs [31]. DM was the most expensive annual cost, estimated to be USD151.32, followed by congestive heart failure at USD104.47, HTN at USD73.44, and CRD at USD69.30. These costs are driven primarily by medication therapy and laboratory testing, and therefore do not present the full cost burden. This same study indicates that a total of USD47,976 is required in necessary fixed start-up costs to establish a new, advanced NCD clinic, serving a population of approximately 300,000 people (USD0.16 per capita). The additional annual operating cost for this clinic was calculated to be USD68,975 (USD0.23 per capita), to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centres. Labour comprised 54 percent of total cost, followed by medications at 17 percent. In addition to the massive direct costs related to NCD treatment and care, society bears massive indirect costs. This mainly concerns productivity losses, as a result of sickness or premature death. In the workplace, absences due to sickness, reduced performance and prolonged absences mount up. The time spent by relatives and loved ones acting as unpaid carers for sick people must also be taken into consideration. Across both direct and indirect costs, there is untapped savings potential as prevention is effective and pays off. Introducing more effective and affordable innovative solutions in screening, managing, and treating NCDs will bring savings. Every RWF invested in NCD care brings cost savings many times greater. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 31

2.4 Health system organisation and coverage of NCD health services NCD services in Rwanda are provided through a mix of public and private systems. Figure 8: Pyramid diagram showing the organisation of Rwanda’s health system NCD services are provided 8 at this level Referral and being decentralised to health centres 4 gradually Provincial hospitals 36 District hospitals / 30 District pharmacies Follow up of stable 509 ˜ Health centres patients mainly ˜885 Health posts Health promotion and awareness 60,000 community health workers The journey of an individual with an NCD starts in their local community, through contact with community health workers who link the patient to a health facility, or when the individual decides to seek care at a local health post or health centre. Each level of health facility treats patients according to its package of services, and each level of care then refers patients who need advanced management upward through the various levels. District hospitals receive suspected HTN, DM, CRD cases from health centres to confirm diagnosis, provide treatment, and identify possible complications. Some are then managed at this level, and others with more severe diseases are escalated to upper level hospitals. Stable patients on medication are referred back to health centres to continue follow-up care. All district hospitals and health centres are meant to provide the minimum WHO Package of Essential NCD Interventions (PEN). This includes health education, screening, referral, and treatment. However, 32 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 effective access to these services is limited due to a lack of availability, either because of funding limitations, insufficient staffing, or delays in the supply chain. There are currently pilot services taking place in 79 health centres across five districts, diagnosing and initiating the treatment of non-complicated NCD cases. Lessons learned in these pilot sites will inform the scale-up of services to remaining district hospitals and raise the capacity of health centres to provide PEN. A WHO report from 2018 indicated good availability of basic medicines, such as insulin, metformin and sulphonylurea for diabetic patients [8]. However, the problem of stockouts remains real, and patients often have to pay OOP to access treatment. This could result in catastrophic health spending and impoverishment. For example, affording two bottles of insulin, costing RWF14,000 per week for some patients, is not possible for many people in Rwanda. The current state of affairs in Rwanda suggests that even though health insurance coverage is high (almost 90 percent of the total population is covered, of which approximately 79 percent are covered by CBHI schemes), the coverage for NCD services may not be as effective and needs further assessment. Within the insurance package, users have to co-pay 10 percent for life-long and expensive conditions like cancer and heart surgery. This can be a very high cost and remains unaffordable for most patients. Chemotherapy drugs for cancer treatment are not yet covered by CBHI or mutuelle de sante, and not yet available in public health facilities. Cancer care and treatment services, including diagnosis, surgery and chemotherapy, are provided at tertiary levels across five diagnostic and treatment centres: The University Teaching Hospital of Kigali (CHUK), University Teaching Hospital of Butare (CHUB), Rwanda Military Hospital, King Faisal Hospital and Butaro Cancer Centre. The national radiotherapy centre at the Rwanda Military Hospital provides a final link to comprehensive cancer treatment. Palliative care services have been integrated at all levels of the health system and there is an encouragement to improve palliative services at the community level so that patients can be cared for at home. To ensure the quality of NCD services, training manuals for various health cadres were developed and disseminated. All health centres therefore have at least one nurse trained in early detection and management of NCDs. Health centres have initiated NCD clinics to treat HTN, asthma and DM. By 2017, all of Rwanda’s 42 hospitals had established NCD clinics, providing management and care of NCDs. In addition, diagnosis and treatment protocols for major NCD diseases were developed and distributed to health facilities. At a primary health care (PHC) level, assorted essential first-line and second-line drugs, as well as medical equipment and supplies, are distributed in line with the national basic package of health services for drugs and supplies. Similarly, staff at primary health facilities are trained in the mechanical operation and handling of diagnosis equipment, materials and tools, such as glucometer, blood pressure measurement, basic glycaemic and lipid profile measurement tools, to maximise the diagnostic quality of testing. National capacity was built for HMIS, and disease surveillance and monitoring. The HMIS platform uses an electronic digital system at PHC level to collect and analyse morbidity data. This electronic database improves the quality of information collected and serves as a tool to provide evidence- based practices, to increase the effectiveness and efficiency of the healthcare system. Currently, all National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 33 health facilities utilise the electronic HMIS platform. In addition, special disease registries have been established to address the issues of M&E of chronic diseases using aggregated data. The current registries collecting individual data include the National Cancer Registry, Injury Registry and the Electronic Medical Records system ‘OpenMRS’ at different hospitals. A key challenge in the prevention and control of NCDs is late presentation, making survival rates of NCD patients very low. Late detection is driven largely by a lack of knowledge and myths about NCD risk factors, prevention and treatment. As stated above, MoH has responded with key initiatives to fight NCDs, including decentralisation of NCD services, and running extensive awareness campaigns. In addition to the car-free days described previously, there is a designated day once a week when civil servants engage in physical activity. In fighting cancer, for example, high-risk groups have been given a free Hepatitis B vaccination to prevent the Hepatitis B virus infection that leads to liver cancer. MoH reports that immunisation against HPV in young girls currently stands at 97 percent of the target group, in a bid to eliminate the incidence of cervical cancer. A key focus for MoH is cervical cancer and breast cancer; currently, about 52 percent of district hospitals and health centres offer screening services. 34 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025

2.5 Key issues facing NCD programming and governance in Rwanda The focus of this strategy is the development of interventions that address the bottlenecks hampering NCD prevention and control in Rwanda. Several outstanding challenges have been identified and informed the development of this strategy: • Low levels of awareness and knowledge of NCD risk factors, symptoms and signs among the general population, leading to late presentation • Insufficient domestic budget allocation for NCD prevention and control activities • Poor resource tracking for NCDs, leading to a lack of planning for each category of NCD and targeted resource mobilisation and allocation • Low budgets for primary health care, potentially leading to insufficient basic NCD equipment at these levels where the majority seek care. For example, in the 2016-2017 healthcare budget, only 10 percent of the total was allocated to health centres where the majority of outpatient services are offered • Lack of an effective M&E system for NCD programming, including poor data capture and reporting • Lack of research leading to proper planning and policy guidance • Unavailability and unaffordability of certain essential medicines and basic technologies for NCD screening and management • Inadequate capacity of health workers (quantity and skills) for the prevention and control of NCDs at all levels of care • Lack of sufficient specialised centres for NCDs management • Weak evidence on multisectoral planning and implementation of interventions for NCD prevention and control • Minimal integration of NCD prevention and control with key public health care platforms such as HIV/AIDS, TB, family planning, maternal and child health • Low numbers of partners active in NCD prevention and care (across public and private sectors, and CSOs) • Some of the most expensive NCDs are not covered by CBHI schemes National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 35

2.6 Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis for the prevention and control of NCDs Table 1: SWOT analysis: Adapted from the Rwanda Biomedical Centre (RBC) NSP for the Prevention and Control of Chronic Non-Communicable Diseases, 2014-2019 STRENGTHS WEAKNESSES Established dedicated and functional NCD Lack of a national multisectoral NCD coordination division at ministry level under RBC mechanism Lack of comprehensive management of NCDs at National guidelines developed for priority NCDs health facilities or community level, including poor resources for advanced NCD health problems Poor HMIS, and lack of representative national National NCD policy data on NCDs Little research or data on chronic diseases and Included within HSSP4 and PRSP their risk factors in the country Lack of links between academics and researchers National cancer control plan 2020-2024 with national policy makers Lack of health promotion materials to address National guidelines for cervical cancer screening a multisectoral list of risk factors (e.g. healthy lifestyle, environment, agriculture) Minimal or poor coordination between public and National palliative care policy private health systems Lack of specialised comprehensive disease Integration of NCD services in existing PHCs management centres (e.g. cancer or CVD centres) Established National Population-Based Cancer No established electronic M&E tools for NCDs Registry Training guidelines for various health care TWG guidelines for NCD implementing partners providers not developed, and TWGs not fully active Health promotional materials developed and Few specialised doctors and other health utilised professionals in NCD diagnosis and management Comprehensive health insurance coverage Low coverage of NCD screening services for the includes major NCDs general population Low capacity (equipment and staffing) at National Tobacco Control Law emergency departments to manage injuries Lack of national integration of mental health into NCD management 36 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 OPPORTUNITIES THREATS Little involvement and experience within Strong and decentralised primary healthcare other sectors (ministries, institutions, and structure stakeholders) in NCD-related problems, including weak inter-sectoral collaboration District hospitals and some health centres Low budget allocation for NCDs provide minimal PEN Lack of resources for NCDs (competing priorities Annual community screening for certain NCDs with major infectious diseases) Limited number of national and international Supportive policy and commitments from the partners for technical and financial support of government NCD programmes WHO ‘best buy’ interventions at PHC level Shortage of health workers in public health are available for preventive and curative NCD facilities services Global initiatives and high-level political Shortage of medical equipment and supplies commitment at global and regional levels to needed for the diagnostic or therapeutic care of support the country’s efforts patients with NCDs Poor awareness and misconceptions about Presence of a professional training institute for the burden and consequences of NCDs, among NCDs (college and universities) policymakers, health professionals and the general public Most NCD diagnosis and treatment services are paid through a co-payment setup between Most NCD screening services are not part of patient and community-based health insurances CBHI schemes schemes Financial toxicity with regards to the payments Regularly organised physical activity initiatives of specialised NCD services such as cancer targeting the general public (e.g. car free days) treatment, limiting accessibility of the low- income population Poor collaboration between MoH/RBC and health teaching universities in planning the integration of NCD national guidelines into curriculums Low utilisation of health services by the general public Low levels of awareness of NCD risk factors among the population Low levels of awareness of NCD symptoms among the population, leading to late presentation at health facilities National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 37 3 METHODOLOGY The process undertaken to develop this strategy is as follows: Preparatory meetings: involved RBC’s NCD unit and The Defeat-NCD Partnership (DNCD) team. These evaluated the progress of the previous strategy and agreed on the strategies to be adopted over the next five years. TWGs and key stakeholders: attended consultative meetings held with the NCD unit team and DNCD to discuss and agree on the strategies to adopt over the next five years. Analytical desk reviews: conducted by the wider team to examine national and international literature informed the strategy formulation process. Some key documents reviewed were the Global NCD Action Plan, HSSP4 and NST. Field visits: conducted to consult and engage districts in drafting objectives and strategies. Consultative workshop: held to collect inputs and ideas, and to set the strategic targets. Participating stakeholders were involved to enrich and guide the development of the strategy. Validation and dissemination: conducted by submitting final documentation to all involved actors and receiving their endorsement, before submission to the Minister of Health for final approval. Figure 9: Stages for the development of the National Strategy and Costed Action Pan for the Prevention and Control of Non-Communicable Diseases in Rwanda Stakeholder Providing and Desk Review Consultations assessing different (second round) scenarios Find Assessment National NCD Data validation Missions costed action plan and triangulation results Stakeholder Data validation and verification Final stakeholder Consultations validation (first round) (from all stakeholders) 5 strategic decisions and Nationa approval Data collection national and dissemination plan consensus 38 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 4 GOAL AND STRATEGIC OBJECTIVES Vision A nation free from the avoidable burden of NCDs, including injuries and disabilities. Mission To enhance national multisectoral collaborations to alleviate the economic, social, and medical burden of NCDs, reduce morbidity and premature mortality, improve functionality, and ensure a healthier population. Goal By 2025, reduce premature mortality from NCDs by 25 percent. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 39 STRATEGIC OBJECTIVE 1 NCD prevention through health promotion and reduction of risk factors Guided by evidence-based and cost-effective approaches, promote healthy lifestyles and implement interventions that reduce the modifiable risk factors for NCDs. These risk factors include unhealthy diets, physical inactivity, tobacco use, harmful use of alcohol, indoor pollution, occupational exposure to carcinogens, and infections leading to NCDs. While symptoms, complications and deaths from NCDs occur mostly in adulthood, exposure to risk factors begin in childhood (even in the intrauterine period) and build to a peak with premature mortality. It is therefore vital that there is a good level of health literacy among the general population, giving people the ability to make personal decisions that will have a positive effect on their health. As the occurrence of NCDs is often caused by various risk factors, more cross-thematic and multisectoral approaches need to be considered. Sectors such as youth and sport, education, trade, agriculture and the environment should work together for NCD prevention. Prevention activities should be designed and carried out to take better account of people’s needs: their settings, such as schools, workplaces and local communities; their living conditions; and their knowledge, values and behaviours. This should focus on improving health status at every stage of life. To achieve this objective, the following operational strategies and strategic actions will be undertaken: PRIORITY AREA 1: Awareness-raising / education to reduce exposure to modifiable NCD risk factors Strategic actions Population-based prevention and health awareness • Establish a school health programme for NCDs, including injuries and disabilities, increasing awareness and prevention as part of primary and secondary school curriculums • Promote community awareness for prevention of NCD risk factors • Introduce the practice of medicine and public health supported by mobile devices, known as mobile health or mHealth, to increase NCD awareness and prevention, and support behavioural change • Strengthen the engagement of CSOs in NCD awareness campaigns 40 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 • Empower districts to run NCD prevention and education programmes • Develop and disseminate NCD prevention communications material targeting the general population. These could focus on balanced diets, reducing alcohol consumption, promoting physical activities and reducing tobacco addiction Prevention and awareness in healthcare • Develop and integrate NCD-related education and awareness messages into the package of services provided at all levels of health care provision • Develop and integrate NCD-related education and awareness messages in the package of services provided by community health workers Awareness and prevention in the workplace • Integrate NCD prevention with occupational health, such as within the workplaces of public and private institutions, and broader public areas PRIORITY AREA 2: Immunisation and early treatment of infections leading to NCDs Strategic actions • Continuous vaccination against Hepatitis B • Early detection, quality treatment and care of Hepatitis B and C infections • Continuous vaccination programme against HPV • Cervical cancer screening and treatment of precancerous lesions • Strengthening and scaling up vaccinations against disabling conditions like poliomyelitis or meningitis • Screening, diagnosis and treatment of rhematic fever and RHD PRIORITY AREA 3: Establish and strengthen the implementation of policies and regulations addressing NCD risk factors Strategic actions Tobacco control • Reinforce the implementation of the 2013 tobacco control policy and action plan National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 41 • Advocate for progressive increases to excise duty and prices for tobacco products, in line with WHO recommendations • Develop and disseminate information and educational material to raise public awareness about the consequences of tobacco use, exposure to tobacco smoke, and encouraging smokers to quit • Establish and implement measures to minimise illicit trade in tobacco products Alcohol use control • Develop and disseminate a national alcohol policy • Support, empower and provide services to individuals or communities engaged in harmful alcohol use • Strengthen community awareness on harmful use of alcohol Promoting healthy diets • Establish regulations or policies related to healthy diets. For example, the trade of trans- fats, sugary beverages, processed food and sodium • Conduct public awareness campaigns, including mass and social media, to inform and engage consumers about healthy diets based on a variety of locally available food and drinks • Promote user-friendly or easy-to-understand food labelling on processed food packaging; and translate international food labels into local languages • Reduce sugar consumption through increased taxation on sugar-sweetened beverages • Raise community awareness of healthy diets, including salt consumption • Promote farming with controlled used of agrochemicals, ensuring crop diversity, and cultivating fruits and vegetables Increasing physical activity • Develop and disseminate guidelines for the general population on physical activity and sports • Create enabling environments for promoting physical activity. For example, through road design and recreational spaces • Increase general awareness on physical activity and its benefits Controlling air pollution and exposure to toxic substances leading to NCDs 42 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 • Strengthen advocacy to support the transition to cleaner technologies and fuels, like liquefied petroleum gas, biogas, solar cookers, electricity, and other low fume fuels • Raise general awareness of the health impacts of indoor air pollution and asbestos risks • Regulate manufacturing of toxic gases and limit their presence in the environment by improving production processes • Enforce the implementation of the National Policy on Occupational Safety and Health PRIORITY AREA 4: Improve road safety for the prevention of injuries and disabilities Strategic actions • Identify and improve accident prone sites or ‘red spots’ • Establish injury data sharing mechanisms between the various concerned stakeholders • Introduce mandatory technical check-ups of motorcycles • Increase awareness among motorcyclists and other public road users on the proper use of roads • Introduce mandatory first-aid training for public transport and truck drivers • Introduce mandatory first-aid kits in public transport and truck drivers • Enforce mandatory medical check-ups (e.g. eyes, ears, disabilities) before issuing or renewing driver licences PRIORITY AREA 5: Deliver on communication plan to accompany the national strategy Strategic actions • Improve external communications skills and increase capacity to support national NCD prevention programme • Develop and implement the National Strategy and Costed Action Plan 2020-2025 communications plan National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 43 STRATEGIC OBJECTIVE 2 Strengthening health systems for quality NCD early detection, care and treatment at all levels A major factor in NCD-related mortality in most LMICs, including Rwanda, is late presentation of cases with complications. This strategy will focus on scaling up NCDs screening, early detection, continuous follow-up, and quality treatment and care, to reduce complications leading to premature mortality. Access to quality health services is at the core of UHC. Ensuring that all patients with NCDs can access quality services requires evidence-based system-wide strengthening: physical infrastructure, equipment, human resources, and the supply chain of medicines and laboratory commodities, to guarantee appropriate and timely screening, diagnosis and treatment of patients to avoid unnecessary complications. The availability, affordability and acceptability of quality health services means that all health facilities are equipped with basic essential clinical equipment and tools for the assessment and management of NCDs and their risk factors. These should be accessible from primary to tertiary levels of care, including specialised centres providing advanced NCD treatment. To achieve this objective, the following strategic actions will be carried out: PRIORITY AREA 1: Human resources development for NCD early detection, care and treatment Strategic actions • Train in-service health care providers in early detection, diagnosis and management of NCDs, including injuries and disabilities, at all levels • Strengthen retention of a skilled NCD workforce, through career development opportunities, continuous learning, credentialing, and privileging • Establish and implement a strong NCD clinical mentorship system, cascaded throughout health system tiers • Integrate national NCD prevention, early detection, care, and treatment guidelines into undergraduate pre-service training of the health workforce • Provide pre-service training (e.g. postgraduate study or fellowships) to ensure adequate numbers of NCD specialists (e.g. oncology, pathology, cardiology, nephrology, emergency medicine, palliative care) • Develop NCD e-learning modules targeting health care providers at all levels 44 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 PRIORITY AREA 2: NCD service delivery Strategic actions • Strengthen the implementation of WHO PEN in primary health care facilities • Expand the implementation of complementary PEN-Plus services, which focus on severe chronic NCDs at district hospitals • Establish NCD early detection, diagnosis, and patient follow-up care for DM and HTN at health posts • Streamline the referral system for NCD prevention, care and management, while ensuring the availability of interoperable, high quality, electronic medical records • Integrate NCD screening, treatment and care into other services, focusing on HIV/AIDS, TB and maternal, child and community health (MCCH) services • Improve physical access for all to health services, including the elderly and people with disabilities • Strengthen the integration of palliative care into existing health care systems • Promote the delivery of palliative care services at home PRIORITY AREA 3: Strengthen the supply chain of NCD medications, laboratory commodities, and technologies/medical equipment Strategic actions • Ensure the continuous availability of essential NCD medicines, supplies and technologies for screening, diagnosis, treatment and monitoring at all levels • Establish and regularly update a list of essential NCD drugs, supplies and equipment at different levels of care National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 45 PRIORITY ACTION 4: Ensure continuous research and development to establish and advance various NCD treatment guidelines and protocols Strategic actions • Establish and regularly update NCD management guidelines and protocols • Monitor the use of guidelines and protocols to ensure quality of care PRIORITY ACTION 5: Financing of NCD prevention and control Strategic actions • Strengthen UHC initiatives through mutuelle de sante (CBHI) to facilitate affordability and sustainable financing of NCD services • Increase the number of NCD services and AT in the benefit package covered by health insurance • Subsidise expensive NCD services for the most vulnerable/poor patients • Include NCD quality improvement indicators into performance-based financing or pay-for- performance systems • Adapt innovative, sustainable and equitable financing mechanisms to ensure UHC for NCD prevention and control PRIORITY ACTION 6: Enhance patient psychosocial and resource support programmes Strategic actions • Strengthen psychosocial and financial support programmes for patients with NCDs • Integrate NCDs with nutrition programmes at health facilities • Integrate NCDs with mental health programmes at health facilities 46 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 PRIORITY ACTION 7: Establish policies and regulations to ensure continued access to NCD services during emergencies such as pandemics or epidemics (e.g. COVID-19) Strategic actions • Ensure continuity of NCD care during emergencies by including NCDs in emergency response plans • Provide alternative platforms for service provision to strengthen health system responses to epidemics or pandemics affecting NCD care • Establish community-based programmes for the protection and care of the most vulnerable, including those with NCDs and persons with disabilities during emergencies, like COVID-19 PRIORITY AREA 8: Establish specialised NCD, including injuries and disabilities, diagnostic and treatment centres Strategic actions • Develop business cases for establishing priority specialised NCD diagnostic and treatment centres, in order to attract funding and private investment • National Cardiac Centre • National Renal Transplant Centre • A Nuclear Medicine Centre • Upgrading of Rwanda Cancer Centre • Upgrading of Pathology services at teaching hospitals • Establishment of Satellite cancer centres in teaching hospitals • Centre of Excellence for Trauma and Rehabilitation • Build and equip new specialised NCD diagnostic and treatment centres National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 47 STRATEGIC OBJECTIVE 3 Strengthen disease surveillance and research, alongside robust M&E systems, for evidence-based intervention Research and surveillance are critical for NCD prevention and control as they provide information that guides policy decisions and empowers the general population. Research into the various components of disease prevention and control – behavioural, health system-related, biomedical, epidemiological and clinical – are critical in producing unbiased information to monitor progress, evaluate plans and support informed policy decisions. Effective M&E systems ensure implementation of planned interventions and programme sustainability. To achieve this objective, the following strategic actions will be carried out: PRIORITY AREA 1: Strengthen disease surveillance and M&E systems Strategic actions • Conduct regular, comprehensive situational analysis of the availability, accessibility, and affordability of NCDs, including injuries, disabilities, and geriatric services • Update standardised NCD M&E frameworks and tools, and integrate them into HIS at all levels • Build the capacity of health staff at all levels in M&E, including protocols for routine surveillance and tracking of NCD data • Strengthen data collection and analysis through national registries and mortality data, including the cancer registry, the injury registry and electronic medical records PRIORITY AREA 2: Enhance research for evidence-based interventions Strategic actions • Establish and implement a national NCD research agenda • Build capacity in NCD clinical research for health professionals at all levels • Conduct NCD risk factors prevalence studies (e.g. a STEPS study, a study on risk factors for cancers) • Conduct a national economic impact study of NCDs • Build capacity around grant writing and manuscript writing 48 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 STRATEGIC OBJECTIVE 4 Strengthen intersectoral coordination, advocacy and resource mobilisation for the prevention and control of NCDs The risk factors for NCDs go beyond the health sector; there is a need to involve other key sectors, such as education, sports, youth, transportation, agriculture and environment, trade, finance and planning. Private partners and civil society organisations also need to be actively involved, to form a multisectoral approach in addressing the increasing burden of NCDs. A truly multisectoral approach requires political will and commitment to succeed in the fight against NCDs. Rwanda has prioritised NCD prevention and control, but advocating for increased funding is required. This is critical as the NCD burden rises in the country, prevention and control efforts will have heavy financial implications. This calls for innovations in health sector funding beyond current government resources. To effectively fund NCD efforts, there is a need to strengthen the country’s NCDs resource mobilisation strategy and governance mechanisms. Only with capacity and legitimacy to mobilise resources and coordinate multisectoral action on NCDs will Rwanda be able to effectively address its NCD burden now and in the future. To achieve this objective, the following strategic activities will be carried out: PRIORITY AREA 1: Establish national mechanisms to coordinate the prevention and control of NCDs Strategic actions • Establish high-level, national, multisectoral NCD coordination mechanisms, including social cluster ministries and key private sector partners • Ensure quarterly meetings of the NCD TWG • Engage government institutions, public and private sectors to collaborate on joint financing mechanisms for NCD prevention and control activities PRIORITY AREA 2: Enhance international, national and decentralised coordination mechanisms for prevention and control of NCDs Strategic actions • Establish NCD committees at district level to enforce NCD care, and strengthen collaboration mechanisms • Create membership to key local and international organisations to enhance training, peer- to-peer learning, and collaborative research • Develop telecommunication platforms that enable information exchange between local and international NCD experts National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 49 5 IMPLEMENTATION, MONITORING AND EVALUATION FRAMEWORK Strategic objective 1: NCD prevention through health promotion and reduction of risk factors Priority area 1: Awareness-raising / education to reduce exposure to modifiable NCD risk factors Population-based prevention and health awareness Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Establish a school School health School health By 2021, MINEDUC MoH / RBC / health programme NCD programme NCD (including MINEDUC reports Baseline: 0 REB / DNCD for NCDs, is established and injury and the availability Target: 1 / WHO / including injuries implemented disability) and dissemination UNICEF / and disabilities, prevention of the curriculum MINALOC / increasing training to the chair of the RRC / District awareness and curriculum NCD multisectoral administration prevention as part available, in- committee of the primary and person and via secondary school e-learning curriculum % of schools Annually, MINEDUC MoH / RBC / implementing MINEDUC reports Baseline: 0 REB / DNCD health % of schools Target: 20% / WHO / programmes with health UNICEF / for NCDs programmes for MINALOC / prevention NCDs (including RRC / District (including injury and administration injuries and disability) to the disabilities) chair of the NCD multisectoral committee 50 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Promote The community Number of Annually, MoH MoH RBC / community has increased country-wide reports the Baseline: 7 MINALOC awareness for awareness and awareness number of Target: 35; 7 / DNCD / prevention of NCD knowledge of and screening country-wide per year SFH / PIH risk factors NCDs risk factors campaigns awareness / Rwanda related to and screening NCD Alliance prevention of campaigns to / CSOs / NCD (including the chair of the Private sector injury and NCD multisectoral disability) risk committee factors Number Annually, MINISPORT MoH / of districts MINISPORT Baseline: 10 MINALOC implementing reports the Target: 30 car free days number of districts implementing car free days to the chair of the NCD multisectoral committee % of the Every four years, MoH RBC / population with MoH reports % Baseline: N/A MINALOC / appropriate of the population Target: 50% PIH / DNCD / knowledge on with appropriate SFH / Private NCD risk factors knowledge on sector / and how to NCD risk factors Rwanda NCD prevent them and how to Alliance / prevent them to CSOs the chair of the NCD multisectoral committee, using various surveys, e.g. STEPS or DHS National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 51 Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Introduce mobile The population Number of Annually MoH MoH RBC / health or mHealth, has access to mHealth reports the Baseline: 0 MINIICT / to increase NCD digital solutions solutions number of Target: 1 RISA / DNCD awareness and to support available implemented / Public prevention, awareness and mHealth solutions sector and support prevention of to the chair of the behavioural NCDs NCD multisectoral change committee % of population Annually, MoH MoH RBC / RURA (with access to reports % of Baseline: 0 / MINIICT / smartphones) population Target: 30% RISA / DNCD using mHealth using mHealth / Public applications on applications sector / WHO awareness and on awareness prevention of and prevention NCDs of NCDs to the chair of the NCD multisectoral committee Strengthen the Increased Number of Annually, MoH MoH RBC / engagement of engagement of CSOs expanding reports the Baseline: TBD MINALOC / CSOs in NCD CSOs in Rwanda their activities number of CSOs Target: TBD DNCD / SFH awareness in NCD-related to include NCD expanding their / Rwanda campaigns activities awareness activities to NCD Alliance include NCD / CSOs awareness to the chair of the NCD multisectoral committee Number of Annually, MoH MoH MINALOC / districts covered reports the Target: 30% RBC / DNCD by CSOs number of districts / SFH / working on covered by Rwanda NCD NCD-related CSOs working Alliance / interventions on NCD-related CSOs interventions to the chair of the NCD multisectoral committee 52 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Empower Districts with NCD Number of Annually, MoH MoH MINALOC / districts to run (including injury districts with reports the Baseline: N/A RBC / CSOs / NCD prevention and disability) specific NCD number of districts Target: 30 Private sector and education prevention (including injury with specific NCD / DNCD programmes and education and disability) (including injury programmes activities and and disability) allocated budget activities and within annual allocated budget plans within annual plans to the chair of the NCD multisectoral committee Develop and NCD prevention Number of Annually, MoH RBC / disseminate communication materials MoH reports Baseline: TBD MINALOC NCD prevention materials developed and the number Target: TBD / CSOs / communications developed and disseminatedw of materials Private sector material disseminated developed and / DNCD / addressing risk disseminated to WHO factors, targeting the chair of the the general NCD multisectoral population committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 53 Prevention and awareness in healthcare Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Develop and NCD awareness % of health Bi-annually, MoH MoH RBC / DNCD integrate NCD- and prevention facilities reports % of Baseline: N/A / SFH / NCD related education messages conducting health facilities Target: 90% Alliance / and awareness integrated at all NCD awareness conducting CSOs / WHO messages into levels of health sessions at least NCD awareness the package of care system once per quarter sessions at least services provided once per quarter at all levels of to the chair of the health care NCD multisectoral provision committee Develop and Community health % of CHWs Annually, MoH MoH RBC / integrate NCD- workers (CHW) trained in NCD reports % of Baseline: 0 MINALOC related education are trained on prevention and CHWs trained in Target: 70% / CSOs / and awareness NCD prevention first-aid skills for NCDs and first- Private sector messages in the prevention aid skills for the / DNCD / the package of and control of prevention and WHO / ICRC services provided injuries and control of injuries / RRC by community disabilities and disabilities to health workers the chair of the NCD multisectoral committee Awareness and prevention in the workplace Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Integrate NCD NCD awareness % of workplaces Annually, MIFOTRA MoH / RBC prevention with and prevention with integrated MIFOTRA reports Baseline: 0 / MINALOC occupational are integrated in NCD prevention the percentage Target: 10% / CSOs / health, such the workplace messages and of institutions Private sector as within the practices providing NCDs / DNCD / workplaces of prevention WHO public and private messages / institutions, and practices at broader public workplace to the areas chair of the NCD multisectoral committee 54 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 1: NCD prevention through health promotion and reduction of risk factors Priority area 2: Immunisation and early treatment of infections leading to NCDs Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Continuous Hepatitis B % of infants that Annually, MoH MoH RBC / GAVI vaccination vaccination receive Hepatitis reports % of Baseline: 93% / UNICEF / against Hepatitis in infants is B vaccination infants that have Target: 93% WHO B optimised received Hepatitis B vaccinations to the chair of the NCD multisectoral committee Early detection, High-risk % of the Annually, MoH MoH RBC / WHO / quality treatment population is population (≥15 reports % of Baseline: 40% CHAI / PIH and care of screened for years) screened target population Target: 80% Hepatitis B and C Hepatitis B and C for Hepatitis B screened for infections infections and C infections Hepatitis B and C infections to the chair of the NCD multisectoral committee Number Annually, MoH MoH RBC / CHAI of patients reports the Baseline: / PIH receiving number of 5,000 for treatment for patients receiving Hepatitis B Hepatitis B and treatment for and 30,000 for C infections Hepatitis B and Hepatitis C C infections to Target: 7,000 the chair of the for Hepatitis B NCD multisectoral and 40,000 for committee Hepatitis C Continuous Young girls aged % of young girls Annually, MoH MoH RBC / GAVI vaccination 12 years are aged 12 years reports % of Baseline: 97% / UNICEF / programme vaccinated against that received target population Target: 97% WHO / DNCD against HPV HPV HPV vaccine that received HPV vaccines to the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 55 Cervical cancer Eligible women % of target Annually, MoH MoH RBC / PIH / screening and (30-49 years) population reports % of Baseline: 10% DNCD treatment of are screened for screened for target population Target: 40% precancerous cervical cancer cervical cancer screened for lesions cervical cancer to the chair of the NCD multisectoral committee Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Continuous Vaccinations % of target Annually, MoH MoH RBC / GAVI vaccinations for poliomyelitis group that reports % of Baseline: 97% / UNICEF / against disabling and meningitis received target population Target: 97% WHO conditions like accessed and poliomyelitis that received poliomyelitis or delivered to and meningitis poliomyelitis meningitis all high-risk vaccines and meningitis populations vaccines to the chair of the NCD multisectoral committee Screening, Decreased rates % of target Annually, MoH MoH RBC / CSOs diagnosis and of rheumatic population reports % of Baseline: N/A treatment of fever diseases screened for target population Target: 40% rhematic fever leading to chronic rheumatic fever screened for and RHD diseases and RHD rheumatic fever and RHD to the chair of the NCD multisectoral committee 56 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 1: NCD prevention through health promotion and reduction of risk factors Priority area 3: Establish and strengthen the implementation of policies and regulations addressing NCD risk factors Tobacco control Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Reinforce the The enforcement % reduction in Every five years, MoH RBC / WHO implementation of of implementation prevalence of MoH reports the Baseline: 13% / CSOs / the 2013 tobacco of 2013 policy tobacco smoking prevalence of Target: 10% DNCD control policy and and action plan is tobacco smoking action plan increased through STEPS Survey Advocate for Increased New tobacco MINECOFIN MINECOFIN MoH / WHO / progressive taxation on locally taxation scheme reports changes in Baseline: 0 MYCULTURE increases to produced and issued tobacco taxation Target: 1 / MINICOM / excise duty and imported tobacco to the chair of the RRA / RBC / prices for tobacco products NCD multisectoral DNCD products, in committee line with WHO recommendations Establish and Enforced laws Rwanda signs MINAFET MINAFET MOH / WHO implement on trade of illicit on the tobacco reports on the Baseline: 0 / MINICOM / measures to tobacco products illicit trade signature and the Target: 1 MINECOFIN / minimise illicit protocol implementation of RBC / DNCD trade in tobacco the tobacco illicit products trade protocol Harmful alcohol use control Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Develop and National alcohol Alcohol policy MoH reports the MoH RBC / WHO / disseminate a policy and action developed and progress towards Baseline: 0 DNCD / PIH / national alcohol plan developed disseminated developing and Target: 1 NCD Alliance policy and disseminated disseminating the / MINICOM national alcohol policy National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 57 Support, empower Alcohol abuse Number of Annually, MoH MoH RBC / WHO / and provide counselling facilities reports the Baseline: TBD DNCD / PIH / services to and therapy providing number of Target: TBD NCD Alliance individuals or programmes alcohol abuse facilities providing communities established and counselling and alcohol abuse engaged in functioning therapy services counselling and harmful alcohol therapy services use to the chair of the NCD multisectoral committee Promoting healthy diets Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Establish Policies and % reduction in Every five years, MoH FDA / RBC regulations or regulations obesity MoH reports Baseline: 2.8% / WHO / policies related on trans-fat, % reduction in Target:2.8% MINAGRI to healthy diets. saturated fats obesity through For example, the and sugar STEPS survey trade of trans-fat, consumption in sugary beverages, place processed food and sodium Promote user- Clearly labelled % of food Annually, FDA FDA MoH / RBC friendly or easy- food products and products with reports % of food Baseline: N/A / FDA / RSB to-understand ingredients clear labelling products with Target: 50% / MINICOM / food labelling clear labelling to DNCD on processed the chair of the food packaging; NCD multisectoral and translate committee international food labels into local languages Reduce sugar Increased New sugar Annually, MINECOFIN MoH / RBC consumption taxation on taxation scheme MINECOFIN Baseline: 0 / RRA / through increased locally produced issued reports the Target: 1 MINICOM / taxation on and imported progress towards DNCD sugar-sweetened sugar-sweetened implementation beverages beverages of a new sugar taxation scheme to the chair of the NCD multisectoral committee 58 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Increasing physical activity Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Develop and Guidelines on Guidelines Annually, MINISPORTS MoH / RBC disseminate physical activity or available and MINISPORTS Baseline: 0 / MINALOC guidelines for the sports developed disseminated reports the Target: 1 / Rwanda general population and implemented progress towards NCDs on physical the development Alliance / activity and sports and dissemination WHO / DNCD of guidelines (public, schools, workplace) to the chair of the NCD multisectoral committee Create enabling Improved % of the Every five MoH WHO / environments accessibility population with years, MoH Baseline: MINISPORTS for promoting to activities, recommended reports % of the ~15% physical activity. facilities or wider levels of physical population with Target: 20% For example, environments activity recommended through road enabling physical levels of physical design and activity activity through recreational STEPS spaces National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 59 Controlling air pollution and exposure to toxic substances leading to NCDs Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Regulate Reduced Number of Annually, MINICOM / MoH / REMA manufacturing of manufacturing factories with MINICOM reports MoEnv toxic gases and and production implemented the number of Baseline: TBD limit presence in emitting toxic measures factories with Target: TBD the environment gases reducing toxic implemented by improving gas emission measures production reducing toxic processes gas emissions to the chair of the NCD multisectoral committee Enforce the Reduced work- Number of work Annually, MINICOM / MoH / REMA implementation related exposure environments MINICOM reports MoEnv of the National to gases and with the number of Baseline: TBD Policy on particles that implemented factories with Target: TBD Occupational cause CRDs and measures implemented Safey and Health cancers reducing work- measures related exposure reducing work- to gases and related exposure particles that to gases and cause CRDs and particles that cancers cause CRDs and cancers to the chair of the NCD multisectoral committee 60 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 1: NCD prevention through health promotion and reduction of risk factors Priority area 4: Improve road safety for the prevention of injuries and disabilities Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Introduce Improved safety % of registered Annually, RNP RNP MININFRA / mandatory for motorcyclists motorcycles reports % of Baseline: 0 MoH / DNCD technical check- completing registered Target: 20% / RBC ups of motorbikes annual technical motorcycles check-ups completing annual technical check-ups to the chair of the NCD multisectoral committee Increase Increased Number of Annually, RNP MoH / awareness among awareness and awareness RNP reports Baseline: 0 MININFRA / motorcyclists knowledge of campaigns the number RBC / WHO and other public motorcyclists conducted of awareness Target: 1 per / DNCD / road users on about the proper campaigns year MINICOM the proper use of use of roads conducted to the roads chair of the NCD multisectoral committee Introduce Increased number % of drivers with Annually, RNP RNP MoH / RBC / mandatory first- of drivers trained proper first-aid reports % of Baseline: 0 ICRC / WHO aid training for on first aid as training drivers with proper Target: 50% / DNCD / public and truck a condition for first-aid training RRC drivers acquiring or to the chair of the renewing a driving NCD multisectoral licence committee Introduce Increased access % of cars with Annually, RNP RNP MoH / mandatory first- to first-aid kits in first-aid kits reports % of cars Baseline: 0 MININFRA aid kits in public case of accidents with first-aid kits Target: 50% and truck drivers to the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 61 Enforce Increased safety % of drivers Annually, RNP RNP MoH / RBC / mandatory and reduced completing reports % of Baseline: 0 DNCD / WHO medical check- unintentional medical check- drivers completing Target: 50% ups (e.g. eyes, injuries ups when medical check- ears, disabilities) acquiring or ups when before issuing or renewing their acquiring or renewing driving driving licence renewing their licences driving licence to the chair of the NCD multisectoral committee Strategic objective 1: NCD prevention through health promotion and reduction of risk factors Priority area 5: Deliver on communication plan to accompany National Strategy and Costed Action Plan 2020-2025 Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Improve external Improved external % of personnel Annually, MoH MoH RBC / DNCD communications communication trained to build reports % of Baseline: 0 skills and increase skills capacity in personnel trained Target: 100% capacity to communication to build capacity support national skills in communication NCD prevention skills to the chair programme of the NCD multisectoral committee Develop and Communications Communications MoH reports MoH RBC / DNCD implement the plan development plan available progress in Baseline: 0 / WHO / national strategy and implemented developing and Target: 1 Rwanda NCD communications implementing the Alliance plan communications plan 62 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 1: Human resources development for NCD early detection, care and treatment Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Train in-service Increased Number of health Annually, MoH RBC MoH / DNCD health care number of care providers reports the number / WHO / Baseline: providers on early qualified, trained in NCDs of healthcare PIH / CHAI / 1,633 detection, diagnosis trained management by providers trained Team Heart / Target: and management healthcare disease category: to the chair of the WDF / RDA 67,340 of NCDs, including providers at integrated NCD NCD multisectoral injuries and all levels to management, committee disabilities, at all provide NCD injuries and levels early detection, disabilities, cancer diagnosis and early detection, management and treatment and palliative care Establish and Increased % of hospitals Bi-annually, RBC MoH / DNCD implement a quality of with bi-annual MoH reports % / WHO / Baseline: strong NCD NCD services mentorship visits of hospitals with PIH / CHAI / 90% clinical mentorship provided at all regular mentorship Team Heart / Target: system, cascaded levels of care visits to the WDF / RDA 100% throughout health chair of the NCD system tiers multisectoral committee % of health centres Quarterly, MoH MoH MoH / DNCD with quarterly reports % of / WHO / Baseline: mentorship visits health centres PIH / CHAI / 40% with regular Team Heart / Target: mentorship visits WDF / RDA 80% to the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 63 Integrate national National NCD % of annual Annually, MINEDUC MoH / RBC NCD prevention, prevention, graduates from MINEDUC reports / DNCD / Baseline: early detection, early detection, medical and nursing the number of UR / Higher N/A care, and treatment care, and schools trained graduates trained learning Target: guidelines into treatment in national NCD in national NCD institutions 80% undergraduate pre- guidelines prevention, early prevention, early with medical service training of are integrated detection, care, detection, care and nursing the health workforce into teaching and treatment and treatment schools / curriculum guidelines guidelines REB / HEC / of medical, annually to the HRHS midwifery, and chair of the NCD nursing school multisectoral undergraduate committee students Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Provide pre-service Increased Number of health Annually, MoH HRHS MoH / DNCD training (e.g. number of care providers reports the number / UR / Higher postgraduate study healthcare who have of health care Baseline: learning or fellowships) to providers completed NCD providers who TBD institutions ensure adequate with NCD sub-specialisation have completed Target: TBD with medical numbers of NCD related sub- fellowships NCD fellowships and nursing specialists (e.g. specialisations specialising in schools / oncology, pathology, NCD care to the REB / HEC cardiology, chair of the NCD nephrology, multisectoral emergency committee medicine, palliative care) Develop NCD Four NCD % of healthcare Annually, MoH MoH HRHS / RBC e-learning modules e-learning providers that reports % of / DNCD / Baseline: targeting health modules completed NCD- healthcare WHO / PIH / N/A care providers at all available related e-learning providers that CHAI / Team Target: levels modules, focused have completed Heart / WDF 50% on cancer, NCD-related / RDA integrated NCD e-learning management, modules, focused palliative care, on cancer, and injuries and integrated NCD disabilities management, palliative care, and injuries and disabilities, to the chair of the NCD multisectoral committee 64 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 2: NCD service delivery Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Strengthen the Increased % of primary health Annually, MoH MoH RBC / DNCD implementation geographical care facilities reports % of health / WHO / Baseline: of WHO PEN access to (district hospitals facilities with full PIH / CHAI / 60% interventions in quality NCD and health implementation Team Heart / Target: primary health care services centres) with full of WHO PEN WDF / RDA 95% facilities nationally implementation interventions to of WHO PEN the chair of the interventions NCD multisectoral committee % of diabetic Annually, MoH MoH RBC / DNCD patients with reports % of / WHO / Baseline: controlled disease Type 2 diabetes PIH / CHAI / 40% (fasting blood patients with Team Heart / Target: glucose level 126, controlled disease WDF / RDA 60% random glucose at hospital level level below 200, to the chair of the HbA1c below 7%) NCD multisectoral committee % of hypertensive Annually, MoH MoH RBC / DNCD patients with reports % of Baseline: / WHO / controlled BP (140 hypertension PIH / CHAI / 40% / 90) patients with Team Heart / Target: controlled disease WDF / RDA 60% at hospital level to the chair of the NCD multisectoral committee Expand the District % of district Annually, MoH MoH RBC / DNCD implementation of hospitals hospitals reports % of / WHO / Baseline: complementary provide that provide provincial and PIH / CHAI / 30% PEN-Plus services, complementary echocardiography- district hospitals Team Heart / Target: which focus on PEN-Plus based management providing WDF / RDA 60% severe chronic services, of heart failure echocardiography- NCDs at district including based hospitals complicated management of severe NCDs heart failure to the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 65 Strategic Expected Indicator Lead Indicators Partners Actions Output Measurement Agency: Establish NCD early Health posts % of health posts By the beginning MoH RBC / DNCD detection, diagnosis, offer NCD providing NCD of 2024, MoH / WHO / Baseline: and patient follow- screening and screening and early reports % of health PIH / CHAI / N/A up care for DM and early detection detection posts providing Team Heart / Target: HTN at health posts NCD screening WDF / RDA 30% and early detection to the chair of the NCD multisectoral committeev Percentage of Annually, MoH MoH B MINALOC eligible people reports % of / CSOs aseline: screened for NCDs eligible people / private 10% in community screened sector / Target: check-ups for NCDs in DNCD 30% community check-ups to the chair of the NCD multisectoral committee Streamline Interconnected % of health facilities Annually, MoH MoH RBC / the referral and with interconnected reports % of health MINIICT / Baseline: system for NCD interoperable electronic medical facilities with RISA / WHO N/A prevention, care digital medical records interconnected / CHAI / Target: and management, records electronic medical DNCD / PIH 20% while ensuring introduced records to the / ENABEL the availability of across the chair of the NCD interoperable, high referral system multisectoral quality, electronic committee medical records Strengthen the Increased Number of health Annually, MoH MoH RBC / ACS / integration of access to facilities with reports the number CSOs / PIH Baseline: palliative care into palliative care functional palliative of health facilities / DNCD / 12 existing health care services care services with palliative WHO / RDA Target: 48 system care services to the chair of the NCD multisectoral committee 66 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 3: Strengthen the supply chain of NCD medications, laboratory commodities, and technologies / medical equipment Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Ensure the Stock outs of % of facilities Annually, MoH MoH RMS Ltd / continuous essential NCD reporting frequent reports the % of RBC / DNCD Target: availability of medicines stock outs of NCD facilities reporting / WHO / <5% essential NCDs reduced at all drugs and supplies frequent stock PIH / CHAI / medicines, levels, across outs of NCD drugs Team Heart / laboratory central stores and supplies to WDF / RDA commodities and and health the chair of the technologies / facilities (Cfr NCD multisectoral medical equipment National committee for screening, Package of diagnosis, treatment services by and monitoring at all level of health levels care delivery) Establish and The list of Updated list of Annually, MoH MoH RMS Ltd / regularly update essential NCD essential NCD reports the RBC / DNCD Baseline: a list of essential medicines, medicines, supplies updated essential / WHO / N/A NCDs drugs, supplies and and equipment NCD medicines, PIH / CHAI / supplies and equipment supplies and Target: 1 Team Heart / equipment at is available equipment from WDF / RDA different levels of and updated an updated list to care regularly the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 67 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 4: Ensure continuous research and development to establish and advance various NCD treatment guidelines and protocols Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Establish and NCDs Number of NCD Bi-annually, MoH RBC / RMS regularly update management management MoH reports the Ltd / DNCD / Baseline: NCD management guidelines guidelines and availability of WHO / PIH / N/A guidelines and and protocols protocols revised updated NCD CHAI / Team Target: 3 protocols are regularly and updated management Heart / WDF revised and every two years guidelines and / RDA updated (integrated NCD protocols to the management chair of the NCD guidelines, cancer multisectoral management committee guidelines and injury management guidelines) Monitor the use Updated % of health facilities Annually, MoH MoH RBC / RMS of guidelines and guidelines and effectively using reports % of Ltd / DNCD / Target: protocols to ensure protocols are national NCD health facilities WHO / PIH / 80% quality of care used at health guidelines and effectively using CHAI / Team facilities protocols national NCD Heart / WDF guidelines and / RDA protocols annually to the chair of the NCD multisectoral committee 68 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 5: Financing of NCD prevention and control Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Strengthen UHC The population Number of new Annually, RRSB RSSB MoH / RBC / initiatives through has increased NCD services reports the number MINECOFIN Baseline: mutuelle de sante financial included in CBHI of new essential / WHO / N/A (CBHI) to facilitate access to NCD benefit packages NCD services DNCD / PIH Target: 4 affordability prevention to include included in CBHI / CHAI / and sustainable and control chemotherapy, benefit packages RDA financing of NCD services screening for to the chair of the services cervical and colon NCD multisectoral rectal cancers, and committee prostheses Include NCD quality Performance- Number of new Annually, MoH MoH RBC / improvement based NCD indictors reports the number MINECOFIN Baseline: 3 indicators into financing included in of new NCD / WHO / Target: 6 performance-based includes performance-based indictors included DNCD / PIH financing or pay- additional financing incentives in performance- / CHAI / for-performance NCDs, based financing RDA systems including incentives to the injuries and chair of the NCD disabilities multisectoral indicators committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 69 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 6: Enhance patient psychosocial and resource support programmes Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Strengthen Psychosocial Number of actors Annually, MoH MoH MINALOC / psychosocial and and financial implementing reports the RBC / WHO Target: 30 financial support support psychosocial and number of actors / DNCD / programmes for programmes financial support implementing PIH / NCD patients with NCDs for NCD programmes for psychosocial and Alliance patients, NCD patients, financial support including injury including injury and programmes and disability, disability for NCDs to the are established chair of the NCD and multisectoral implemented committee Integrate NCDs NCDs and % of health facilities Annually, MoH MoH MINALOC / with nutrition nutrition with integrated reports % of health RBC / WHO Baseline: programmes at programmes NCDs and facilities with / DNCD / N/A health facilities are integrated nutritional services integrated NCDs PIH / NCD Target: at health facility and nutritional Alliance 80% level services to the chair of the NCD multisectoral committee Integrate NCDs NCDs and % of health facilities Annually, MoH MoH MINALOC / with mental health mental health with integrated reports % of RBC / WHO Baseline: programmes at programmes NCDs and mental health facilities / DNCD / N/A health facilities are integrated health services with integrated PIH / NCD Target: at health NCDs and mental Alliance 80% facilities health services to the chair of the NCD multisectoral committee 70 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 7: Establish policies and guidelines to ensure continued access to NCD services during emergencies such as pandemics or epidemics (e.g. COVID-19) Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners Ensure continuity NCD services NCD services MoH reports MoH RBC / RMS of NCD care during included in included in national the inclusion of Ltd / DNCD / Baseline: emergencies by emergency emergency plans NCD services WHO / PIH / N/A including NCD response plans in national CHAI / Team Target: 1 care in national emergency plans Heart / WDF emergency to the chair of the / RDA response plans NCD multisectoral committee Provide alternative Continuous Number of Annually, MoH MoH RBC / RMS platforms for availability and alternative reports the number Ltd / DNCD / Baseline: 1 service provision to accessibility platforms, like of alternative WHO / PIH / Target: 3 strengthen health of NCD mHealth and other platforms in CHAI / Team system responses services during IT platforms, in place to ensure Heart / WDF to epidemics or emergencies place to ensure continuity of / RDA pandemics affecting continuity of care care during NCD care emergencies to the chair of the NCD multisectoral committee Establish Communities % of CHWs able to Annually, MoH MoH RBC / RMS community-based are provide support to reports % of Baseline: 0 Ltd / DNCD / programmes for empowered the most vulnerable, CHWs able to Target: WHO / PIH / the protection and and supported including those with provide support 25% CHAI / Team care of the most to ensure the NCDs and persons to NCD patients Heart / WDF vulnerable, including protection and with disabilities, and persons with / RDA those with NCDs care of NCD during emergencies disabilities during and persons with patients during emergencies disabilities, during emergencies annually to the emergencies like chair of the NCD COVID-19 multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 71 Strategic objective 2: Strengthening health systems for quality NCD early detection, care and treatment at all levels Priority area 8: Establish specialised NCD, including injuries and disabilities, diagnostic and treatment centres Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency: Partners “Develop business Business Number of business Annually, MoH MoH RBC / cases for cases for cases developed to reports the number DNCD / PIH Baseline: 0 establishing priority specialised attract investment of business cases / CHAI / Target: 8 specialised NCDs NCD developed to MINECOFIN diagnostic and diagnostic attract investment treatment centres, and treatment to the chair of the in order to attract centres are NCD multisectoral funding and private developed committee investment: - National Cardiac Centre - National Renal Transplant Centre - A Nuclear Medicine Centre - Upgrading of Rwanda Cancer Centre - Upgrading of Pathology services at Teaching Hospitals - Establishment of Satellite cancer centres in Teaching Hospitals - Centre of Excellence for Trauma and Rehabilitation Build and equip new The general Number of Annually, MoH MoH RBC / specialised NCDs population new, functional, reports the number DNCD / PIH Baseline: diagnostic and has increased specialised NCD new, functional, / CHAI / N/A treatment centres access to diagnostic and specialised NCD MINECOFIN Target: 3 specialised treatment centres diagnostic and / private NCD treatment centres sector / diagnostic to the chair of the investors and treatment NCD multisectoral services committee 72 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 3: Strengthen diseases surveillance and research, alongside robust monitoring and evaluation system, for evidence-based intervention Priority area 1: Strengthen diseases surveillance and M&E systems Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Conduct regular, Situational One situational MoH reports RBC MoH / CDC / comprehensive analysis report analysis report on progress Baseline: 0 WHO / DNCD situational available published towards Target: 1 / CHAI / PIH analysis of the before the publishing availability, completion of a situational accessibility, and the national analysis report affordability of strategic plan in 2025 to the NCDs, including chair of the NCD injuries, disability multisectoral and geriatric committee services Update HMIS indicators HIS system Every two years, Baseline: N/A MoH / CDC / standardised updated to includes MoH reports Target: 1 WHO / DNCD NCD M&E include relevant priority NCDs, on progress / CHAI / PIH frameworks NCDs, including including injury towards and tools, and injuries and and disability including integrate them disabilities indicators priority NCD into HIS at all (including injury levels and disability) indicators to the chair of the NCD multisectoral committee Build the Data managers % of data Annually, MoH MoH RBC / CDC / capacity of and M&E staff managers and reports % of Baseline: WHO / PIH / health staff at are reporting M&E officers data managers 50% DNCD / CHAI all levels in quality data on trained in M&E trained in M&E M&E, including NCD indicators and reporting and reporting Target: 80% protocols (including skills skills to the for routine injury and chair of the NCD surveillance and disability) multisectoral tracking of NCD committee data National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 73 Strengthen National National Annually, RBC MoH / WHO data collection registries cancer registry MoH reports Baseline: 20 / IARC / and analysis for specific decentralised the coverage Target: 80 AFCRN / PIH through national diseases and to all hospitals of national / Einstein- registries mortality data and clinics cancer registry Rwanda and mortality are established (facilities Research data, including and covered) to the and Capacity the cancer operational chair of the NCD Building registry, the multisectoral Programme injury registry committee and electronic medical records Injury registry Annually, MoH MoH TBD decentralised reports the Baseline: 2 to hospitals number of Target: 10 hospitals with national injury data to the chair of the NCD multisectoral committee % of health Annually, MoH MoH RBC / WDF / centers with reports % of Baseline: 5% WHO / PIH / operational health centers Target: 100% DNCD electronic with operational medical record electronic systems medical record systems to the chair of the NCD multisectoral committee 74 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 3: Strengthen diseases surveillance and research, alongside robust monitoring and evaluation system, for evidence-based intervention Priority area 2: Enhance research for evidence-based interventions Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Establish and NCD national Research Annually, MoH RBC MoH / PIH / implement a research priorities reports on Baseline: 0 PIH / CHAI / national NCD agenda is and agenda progress and Target: 1 WHO research agenda developed and developed and implementation disseminated adapted of identified priorities to the chair of the NCD multisectoral committee Build capacity e-training on e-learning Annually, MoH RBC MoH / CDC / for health research skills developed and reports on Baseline: 0 WHO / DNCD professionals at developed and disseminated progress and Target: 1 / PIH / CHAI all levels in NCD undertaken by implementation clinical research NCD staff at all of identified levels priorities to the chair of the NCD multisectoral committee Number of Annually, MoH RBC MoH / CDC / NCD staff reports the Baseline: 0 WHO / DNCD who have number of NCD Target: 20 / PIH / CHAI completed staff who have the clinical completed the research clinical research e-training e-training to the chair of the NCD multisectoral committee National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 75 Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Conduct NCD STEPS report One STEPS Every five years, RBC MoH / WHO risk factors report MoH conduct a Baseline: N/A / CDC / prevalence produced comprehensive Target: 1 ENABEL / studies (e.g. a STEPS Bloomberg / STEPS study, DNCD a study on risk factors for cancers) Conduct Economic Economic MoH reports RBC DNCD / MoH a national cost study cost study on progress in Baseline: 0 economic impact conducted and conducted conducting and Target: 1 study of NCDs published on disseminating international results of an platforms economic cost study Build capacity NCD staff have Number of Annually, MoH RBC MoH / PIH / around grant capacity built manuscripts reports the Baseline: N/A DNCD / WHO writing and in grant writing and grant number of / CHAI manuscript and reports proposals manuscripts and Target: 20 writing developed and grant proposals published developed and published to the chair of the NCD multisectoral committee 76 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Strategic objective 4: Strengthen intersectoral coordination, advocacy and resource mobilisation for the prevention and control of NCDs Priority area 1: Establish national mechanisms to coordinate the prevention and control of NCDs Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Establish high- A multisectoral An active NCD MoH reports MoH N/A level, national, coordination multisectoral establishment Baseline: 0 multisectoral mechanism coordination of an NCD Target: 1 NCD coordination for NCDs mechanism multisectoral mechanisms, established established coordination including social committee cluster ministries and key private sector partners Ensure quarterly NCD TWGs Number of Annually, RBC MoH / meetings of the are established TWG meetings MoH reports Baseline: 0 WHO / NCD TWGs and functional the number Target: 4 per DNCD / of meetings year PIH / CHAI of TWGs to the chair of the NCD multisectoral committee Strategic objective 4: Strengthen intersectoral coordination, advocacy and resource mobilisation for the prevention and control of NCDs Priority area 2: Enhance international, national and decentralised coordination mechanisms for prevention and control of NCDs Strategic Expected Indicator Lead Actions Output Indicators Measurement Agency Partners Establish NCD District level Number of MoH reports MINALOC MOH / committees at NCD commit- districts with the number of Baseline: 0 RBC / district level to tees estab- active NCD districts with Target: 30 private enforce NCD care, lished committees active NCD sector / and strengthen committees JADF collaboration mechanisms National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 77 6 NATIONAL COSTED ACTION PLAN FOR THE PREVENTION AND CONTROL OF NCDS To determine the resource needs for delivery of the strategic objections and actions listed above, analysis was conducted using WHO’s OneHealth Tool.

6.1 Introduction

6.1.1 The need for costing Implementing a programme has cost implications which need to be accurately estimated for successful programme implementation. Full knowledge of the cost of service delivery guides resource allocation decisions, which have an impact on patient care and health outcomes [32]. Tough decisions are made, particularly in resource constrained settings, as resources allocated for one programme may mean that other competing programmes have reduced resources, i.e. resource allocations need to be guided to the most cost-effective interventions. Thus, ministries of health across the world require reliable information on condition-specific costs and patient outcomes to make informed resource allocation decisions and cost-benefit trade-offs [33]. Such information is also required by governments to understand the budget implications of each strategy and how public funds would be managed for effective implementation. A properly costed strategy, therefore, not only strengthens the quality of strategic documents, but also enhances transparency and accountability in managing public resources. It also helps in avoiding implementation failures emanating from poorly costed strategies. Accurate estimates on both health effects and costs is essential in making these decisions [34].

6.1.2 Costing the NCD strategy This document details the efforts of every actor involved in the prevention and response to NCDs, together with comprehensive cost information for a given period of time, usually in the medium term (3-5 years). This national costed action plan shows in detail the financial resources needed to cover the cost of every effort that is delivered in the prevention or treatment of NCDs and their complications. It allows for a comprehensive resource mobilisation effort and gives funders the possibility to identify with priorities within the total action on NCDs and thus to decide which specific efforts they want to contribute to. 78 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Objectives and scope of the National Costed Action Plan The purpose of including a national costed action plan alongside Rwanda’s national strategy for prevention and control of NCDs for 2020 to 2025, is to guide NCD-related investments to make NCD services universally accessible and affordable for all. The objectives of costing the plan are: 1. To assess resource needs, identify resource gaps and project future costs of strategic NCD plans for policy, management, and budgeting purposes. 2. To estimate costs of scaling up NCD service coverage in the context of UHC (affordable and accessible NCD services for all). 3. To provide a roadmap for sustainable financing of NCDs in Rwanda. The costing exercise takes the perspective of the government, since most Rwandans (up to 80 percent of the population) are covered by health insurance, that is mainly public, and there is a government commitment to attain UHC by 2022. The provider types considered in the exercise are public and faith-based organisations (FBO). Facility types include all tiers of service: health posts, health centres, district and provincial hospitals, referral hospitals, as well as all FBO clinics and hospitals. All levels of service (primary, secondary and tertiary) are considered in the costing exercise. Both recurrent (e.g. personnel, drugs and non-drug pharmaceuticals, utilities) and non-recurrent costs (infrastructure and other equipment) are costed where necessary. The total costs are estimated on an annual basis and projections made from the beginning of 2021 to the end of 2025.

6.1.3 Choice of costing tool: the OneHealth Tool (OHT) OHT (v4.671) is a software tool for strategic health planning which provides projected cost scenarios for health plans at a national level. The tool is used for medium-term strategic health planning (3-10 years) at national level, although it can be adapted for sub-national (district, province, county) health planning. OHT was developed by WHO to respond to country requests for a single tool that reflected the best aspects of existing tools; a key advantage of OHT is that it incorporates already established models and best practices from at least nine other tools [35].

6.1.4 The costing process Costing the NCD plan was a consultative and iterative process of formulating objectives, data collection, baseline analysis, setting targets and quality assurance to ensure accuracy of cost estimates. The phases of the costing exercise were as follows: National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 79 • Configuration of the tool to the Rwandese context including population and economic growth projections, as well as health care data such as NCD drugs and non-drug pharma, number and types of health workers, health facilities and general infrastructure. • A presentation of the methodology and tool for validation by stakeholders. • Data collection and cleaning by the technical focal persons from the Defeat-NCD Partnership and MoH. • Validation of activities, treatment inputs and unit costs. • Data analysis, report writing and stakeholder review of the report.

6.2 Methodology of the OneHealth Tool

6.2.1 Configuration of the OHT Organisation and interventions • The programme area is NCDs, but HPV vaccine costs are excluded as this is a separately funded intervention. • The sub-groups were set as follows in accordance with Rwanda’s NCD priorities: CVD and diabetes, breast cancer, cervical cancer, prostate cancer, colorectal cancer, oral care and cancer, and respiratory diseases. Others are emergency care for injuries, risk factors and policy interventions. • Delivery channels are the five tiers of Rwanda’s health system: health post, health centre, district hospital, provincial hospital, and national referral hospitals. The services costed under each NCD are in accordance with standard treatment guidelines and were verified by MoH teams. The verification included service scope by facility (e.g. laboratory, drugs and supplies) and the unit costs.

6.2.2 Health system costs (shared costs) All data inputs, outlined below, are tabulated in Annex 1. The health system strengthening costs (indirect costs for NCDs) are shared costs between NCDs and all other services. The model apportions shared costs based on time spent by health personnel on a particular service. 80 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Infrastructure Data for infrastructure was obtained from MoH’s Civil Engineering Department. Data included facility baseline (numbers and types), construction costs, rehabilitation costs (basic and extensive) and operation costs for all levels of care. Targets were based on population norms. The model calculates infrastructural (health facility) needs based on population norms. The average number of beds and average number of outpatient (OP) visits and inpatient (IP) days were retrieved from Rwanda’s statistical yearbooks [36, 37]. Previous studies by Collins et al. [38, 39] and WHO-CHOICE [34] were used to estimate average OP costs per visit and cost per IP day. Input for human resources for health (HRH) Projections for HRH needs were calculated based on policy decisions instead of target setting. This is well articulated in the human resources for health policy of 2014 [40]. The policy lays emphasis on integrated services that account for the following: • Decentralised implementation of the HRH policy and strategy in accordance with the national health decentralisation strategy. • Enhanced local health systems: improve district health governance, innovative planning, enhance local recruitment and district service operationality. • Sustainable linkages to improve overall service delivery. Estimates of HRH requirements between 2020 and 2025 were obtained from a 2019 Health Labour Market Analysis Report by MoH [41]. For HRH salaries, the International Labour Organisation’s average wage growth rate for Africa (2.6%) was used in the projections [42]. Human resources data that have been considered in the costs include baseline data (numbers and type), salaries and benefits, time utilisation, attrition, and recruitment rates, as well as in-service training costs. Apart from shared personnel, there are 88 nurses and 14 national officers specifically working on NCDs. Financing and fiscal space The Rwanda health resource tracking report [43] provided the necessary input for financing data including trends in each funding source (public funding, donor agencies, households and private insurance). The Gross Domestic Product (GDP) growth rate was projected at 2 percent on average, while general government expenditure was projected at 6.45 percent on average, based on a decade- long trend (2009-2018). All expenditures were entered in absolute figures. The modelling for fiscal space considered current trends in government spending as well as the GDP growth rate. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 81 Health information systems MoH has documentations of unit costs for various activities including meetings, campaigns, workshops (large and small), training, monitoring and supervision visits, and hardware and networking. These unit costs were used in the programme estimates. MoH provided the numbers of activities required. Currency and inflation On average, the inflation rate in Rwanda for 2020-2025 was placed at three percent, based on trends for the last 10 years (3.7% on average) and future projections (2.4%) [44]. United States Dollar (USD) inflation was calculated at 0.35 percent. The USD exchange rate was set at RWF 951.8 on average for 2020, and factored in dollar inflation at 0.3 percent.

6.2.3 Service costs (NCD specific services) NCD service coverage and target setting Baseline data was obtained through review of published literature [45-56] and information from disease registries. Targets were set by MoH teams and guided by WHO global targets for NCDs. Population targets for coverage by each NCD service, e.g., screening services, treatments, were set by MoH. Due to lack of national data, baseline and targets for cancer were set with data from WHO estimates . Due to a similar lack of accurate national data on cancer incidence (all sites), WHO used estimates [57] from neighbouring countries partitioned using frequency data. The findings suggest that there were about 10,704 new cases of cancer in Rwanda in 2018, of which only a few were diagnosed. For example, of the estimated 1,304 cases of cervical cancer, only 351 (27%) were diagnosed of which 51 of diagnosed cases were at stage 1, 91 at stage 2, 144 at stage 3, and 65 at stage 4. That means, at the baseline, only about 4 percent of estimated cases were diagnosed at stage 1, 7 percent at stage 2, 11 percent at stage 3, and 5 percent at stage 4 (Table 2). Table 2: Baseline and targets based on WHO estimates Cancer WHO Diagnosed Stage 1 Stage 2 Stage 3 Stage 4 site estimates 2018 % 2018 No Baseline Target No. Baseline Target No. Baseline Target No Baseline Target Cervical 1304 351 27 51 4% 10% 91 7% 25% 144 11% 15% 65 5% 10% cancer Breast 1131 393 35 44 4% 10% 114 10% 25% 123 11% 15% 112 10% 15% Cancer Colon 750 137 18 10 1% 8% 30 4% 12% 50 7% 15% 44 6% 10% Rectal Prostate 707 The figures as shown could not be used as a baseline, because the estimates are quite dated and did not consider recent efforts to improve cancer diagnosis, and the observation that up to 70 percent 82 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 of cases actually get diagnosed at stage 4 [58], contrary to the information on the table. The baselines were therefore adjusted accordingly (Annex 2). Drugs and supplies Stock lists with unit costs were obtained from RBC’s Procurement Division, for 2020 prices. Cancer drugs and their unit costs were provided by MoH’s NCD Division as they are not all procured by the Procurement Division. The projections for 2025 prices were based on contract agreements with suppliers which state a three-year no-price-change contract. Also considered were trends in medical and general inflation as well as government policies on pharmaceutical price controls. The period 2021-2025 was assumed too short for discounted prices. All treatment inputs were guided by Rwanda’s national benefits package and defined by the MoH team, which helped in clarifying the scope of services offered at each level of care.

6.2.4 Costs estimated outside the tool Prostate cancer Costs were calculated based on available literature. The annual cost of prostate cancer treatment was estimated at USD 13,200 per case. An assumption was made that at any time during each year there are about 570 prostate cancer cases receiving government treatment. The 570 cases were based on projections that there are about 10,504 new cancer cases in Rwanda each year, of which 5.4 percent are prostate cancer. The costs were inflation-rated at 3 percent per annum from 2021 to 2025. Oral cancer A similar budget for dental cleaning and preventive care has been placed on oral cancer treatment. For emergency care needs These were based on data provided by MoH’s Injuries and Rehabilitation Unit. Estimates were based on 540,000 annual OP visits at RWF 2,500 on average per visit, and about 41,000 IP stays at RWF 4,500 per inpatient stay for four days on average. These were inflation-rated at 3 percent per annum.

6.2.5 Framework for NCD Costing and Sustainable Financing The framework for the costed action plan is represented in Figure 1. The objective of the costing work is to estimate NCD costs and explore the overall financial sustainability of the health system. This requires an understanding of the current funding features to be able to estimate available revenue, versus the cost of planned expenditure, including costs of NCDs and all other health programmes. This enables the identification of potential funding gaps and development of financing systems to address the gaps over the long-term. As a contributor to overall health system costs, NCD costs include prevention and screening services, treatment and infrastructure, human resources, among other items. Shared costs include personnel time and operational costs from the utilisation of system-wide infrastructure during IP and OP services. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 83 The capacity of the economy to finance the planned expenditure factors needs to consider parameters such as population growth rate, economic growth rate, service utilisation and unit costs. The results of the assessment of these parameters should inform next steps in establishing sustainable financing mechanisms for NCDs and the health system. Figure 10: A Framework for NCD Operational Plan Costing and Sustainable Financing Expenditure projections System costs NCDs specifc costs Current health system funding Health systems NCDs service delivery strenghtening cots specifc costs Human Prevention & Infrastructure Infrastructure Resources HIS Treatment NCDs specifc screening & other Logistics Financing Governance Available revenue Total health expenditure Total NCD expenditure • NCDs specifc Funding gap •NCDs specifc 1. Design Sustainable financing 2. Develop mechanisms 3. Review Service utilization Cost of service Population Economic growth rate • NCDs specifc • NCDs specifc growth rate • NCDs specifc Service efficiency, Strategic purchasing, Innovation Health expenditure Sustainable health Revenue generation NCDs specific financing In summary, developing sustainable financing for NCDs and the health system, requires reflections on several issues, including key cost drivers such as service utilisation and unit costs, as well as revenue drivers such as population size and economic growth rate. Important issues such as efficiency and equity trade-off, strategic purchasing, and financing innovations, need to be fully considered to contain costs and ensure that needed services universally reach the target population. 84 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025

6.3 Results

6.3.1 Summary of Costs The implementation of the strategic plan will require about RWF 358.1 billion (USD 376.2 million) for the period of the plan (2021-2025), beginning with an initial investment of about RWF 51.3 billion in 2021 (USD 53.9 million) (Table 3). Table 3: Total cost of NCD prevention and control (USD 1 = RWF 952) 2021 2022 2023 2024 2025 Total Drugs and supply 42,853,630,241.91 50,486,879,151.86 63,485,143,431.56 75,118,372,056.54 87,419,559,521.59 319,363,584,403.46 costs Total programme 8,487,062,609.90 7,998,735,977.49 9,875,727,290.27 6,304,301,090.79 6,108,638,949.88 38,774,465,918.33 costs Total cost (RWF) 51,340,692,851.81 58,485,615,129.35 73,360,870,721.83 81,422,673,147.33 93,528,198,471.47 358,138,050,321.79 Total cost (USD) 53,929,299.21 61,434,469.67 77,059,738.15 85,528,018.01 98,243,905.96 376,195,431.01 Other costs (Table 4) are labour (time for non-NCD specific personnel) and administrative costs such as utilities that are incurred during outpatient and inpatient services. These costs are often budgeted for by the administrative/human resource department and therefore not very consequential budget- wise in operational costing for NCD prevention and control. Table 4: Other costs (shared) (RWF) 2021 2022 2023 2024 2025 Total Labour costs 308,086,967.73 426,677,236.17 559,325,739.29 709,654,675.58 879,571,932.96 2,883,316,551.74 IP / OP costs 16,753,872,227.29 21,120,454,027.02 25,700,920,926.81 30,623,610,908.47 35,918,857,401.74 130,117,715,491.34 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 85

6.3.2 Intervention Costs (Drugs and Supplies) Table 5 gives a breakdown of total treatment input costs including preventive measures by intervention area. Table 5: Breakdown of NCD intervention costs (RWF billions) Intervention area 2021 2022 2023 2024 2025 CVD and diabetes 15.97 21.14 26.75 32.95 39.41 Breast cancer 6.44 7.99 9.65 11.45 13.41 Cervical cancer 1.87 2.16 2.47 2.81 3.19 Colorectal cancer 0.08 0.1 0.12 0.14 0.16 Dental cleaning and preventive care 1.04 0.13 1.58 1.88 2.22 Oral cancer treatment 1.04 0.13 1.58 1.88 2.22 Prostate cancer 7.12 7.34 7.56 7.78 8.02 Respiratory disease 7.12 9.18 11.32 13.58 15.97 Injuries 2.09 2.15 2.22 2.28 2.35 Risk factor reduction 0.08 0.16 0.26 0.37 0.47 Total 42.85 50.48 63.51 75.12 87.42 The figures in Table 5 indicate that the main cost drivers are CVD and diabetes interventions, cancers in general (and breast cancer in particular), and respiratory illnesses. A few interventions have been identified as constituting the single largest cost drivers in each disease programme. These include standard glycaemic control (RWF 30.2 billion by 2025), screening for CVDs and diabetes (RWF 18.2 billion), treatment of rheumatic heart disease with benzathine penicillin (RWF 16.5 billion), trastuzamab drug for breast cancer (RWF 3.6 billion) and asthma treatment with ‘low-dose inhaled beclometasone + SABA’ (RWF 2.5 billion), by 2025. As shown in Figure 10, CVD and diabetes programmes have the largest share of the costs which are estimated to rise from about RWF 16 billion in 2021 to RWF 39.4 billion in 2025. This is followed by cancers (RWF 17.6 billion in 2021 to 29.2 billion in 2025), respiratory illnesses (RWF 7.1 billion to 16 billion), over the period 2021 to 2025. 86 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Figure 11: NCD treatment costs (RWF billions) 100 2,35 90 80 2,28 15,97 70 2,22 13,58 CVD & Diabetes 60 11,32 29,22 50 2,09 25,94 Cancers 9,18 40 7,12 22,94 Respiratory disease 30 17,84 17,60 Injuries 20 30,41 26,75 32,95 10 15,97 21,14 0 2021 2022 2023 2024 2025

6.3.3 Programme costs Programme costs in Table 6 amount to about RWF 8.5 billion in 2021 but fall to RWF 6.1 billion in 2025. The fall in expenditure is explained by heavier investment in the first three years of implementing the strategy. There is a need to increase programme expenditure, particularly in relation to public awareness, to shift focus from curative services to the prevention and control of NCDs. Table 6: Breakdown of programme costs 2021 2022 2023 2024 2025 1. Human Resources for NCDs 523,653,709.60 533,547,313.20 535,433,619.60 537,264,446.40 539,261,712.00 2. Training 391,142,199.70 367,867,049.37 310,424,310.18 52,865,234.36 39,085,302.16 In-service / refresher training 348,671,218.05 362,247,201.54 304,784,593.92 47,206,234.02 33,405,264.64 Other workshops 42,470,981.65 5,619,847.82 5,639,716.27 5,659,000.34 5,680,037.52 3. Supervision 67,889,800.00 68,595,945.22 68,838,459.74 69,073,841.48 69,330,621.56 4. Monitoring and Evaluation 526,869,997.75 70,728,091.86 70,978,144.39 71,220,842.42 71,485,603.92 Design / review of data systems 69,999,997.75 70,728,091.86 70,978,144.39 71,220,842.42 71,485,603.92 STEPS and NCD cost surveys 456,870,000.00 - - - 5. Infrastructure and Equipment 5,885,598,362.87 5,881,042,694.47 7,809,573,232.67 4,489,976,228.00 4,301,843,240.00 Equipment upgrades for hospitals 2,807,020,006.00 2,836,216,789.00 2,846,243,967.00 2,855,976,228.00 2,866,593,240.00 Medical equipment 3,078,578,356.87 3,044,825,905.47 4,963,329,265.67 1,634,000,000.00 1,435,250,000.00 6. Outreach (risk factors) 1,085,216,548.40 1,070,193,286.07 1,073,694,021.40 1,077,091,793.94 1,080,798,454.88 Policy formulation 25,216,579.93 - - - - Social outreach activities 1,059,999,968.47 1,070,193,286.07 1,073,694,021.40 1,077,091,793.94 1,080,798,454.88 7. Advocacy 6,691,991.58 6,761,597.30 6,785,502.29 6,808,704.19 6,834,015.36 Planning an advocacy strategy 6,691,991.58 6,761,597.30 6,785,502.29 6,808,704.19 6,834,015.36 Total programme costs 8,487,062,609.90 7,998,735,977.49 9,875,727,290.27 6,304,301,090.79 6,108,638,949.88 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 87 Details of the training activities are in Annex 1 under ‘Training programmes’ and are targeted towards improvements in quality of NCD service delivery. Supervision costs include biannual national mentorship and supervision visits to the districts, as well as once-a-year mentorship and supervision from the districts to the local health facilities. The main cost drivers under M&E are the planned STEPS survey and NCD economic cost study. Proposed equipment purchases for CVDs, diabetes, and cancer, as well as data system upgrades, are captured under infrastructure and equipment. Under outreach, there are at least seven activities planned each year, besides monitoring risk factors including alcohol consumption, tobacco use, physical inactivity, and diet. The details are contained within the wider strategic plan.

6.3.4 Costs by strategic objectives STRATEGIC OBJECTIVE 1 NCD prevention through health promotion and reduction of risk factors The costs considered here include those related to awareness creation, risk factor reduction through screening and treatment, as well as treatment for infections leading to cancer. Screening services include CVDs and diabetes, breast and cervical cancers (Table 7). Table 7: NCD prevention and risk reduction (RWF) Cost area 2021 2022 2023 2024 2025 Screening 1,789,179,576.15 2,625,362,812.27 3,545,659,568.68 4,570,049,156.69 5,706,524,852.89 Follow-up care (secondary 272,672,257.34 330,133,225.42 388,748,842.95 450,500,295.31 515,831,040.19 prevention) Basic breast cancer 3,609,197,713.23 4,370,821,346.66 5,154,463,490.19 5,986,412,905.67 6,872,600,309.81 awareness Dental cleaning and 1,043,688,086.09 129,942,199.80 1,575,848,697.19 1,881,784,946.87 2,219,204,109.46 preventive care Risk factor reduction 76,495,374.67 162,684,603.67 259,311,066.58 367,457,193.98 473,896,760.74 (health facility-based) Awareness campaigns 1,085,216,548.40 1,070,193,286.07 1,073,694,021.40 1,077,091,793.94 1,080,798,454.88 (risk factor reduction) Advocacy 6,691,991.58 6,761,597.30 6,785,502.29 6,808,704.19 6,834,015.36 Total 7,883,143,568.45 8,695,901,093.19 12,004,513,212.27 14,340,107,020.67 16,875,691,568.34 88 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 STRATEGIC OBJECTIVE 2 Strengthening health systems for quality NCD early detection, care and treatment at all levels Under the second objective, the costs include salaries and skills training for human resources, NCD treatment, mentorship and supervision for quality care, and medical equipment purchases (Table 8). Table 8: NCD early detection, quality care and treatment (RWF) Actions 2021 2022 2023 2024 2025 Human resources for 523,653,709.60 533,547,313.20 535,433,619.60 537,264,446.40 539,261,712.00 NCDs NCD service delivery 348,671,218.05 362,247,201.54 304,784,593.92 47,206,234.02 33,405,264.64 training Injury-related training 34,858,589.95 5,619,847.82 5,639,716.27 5,659,000.34 5,680,037.52 Supervision/ 67,889,800.00 68,595,945.22 68,838,459.74 69,073,841.48 69,330,621.56 mentorship NCD treatment (drugs, 36,138,892,609.10 43,030,619,567.71 52,820,422,832.55 62,229,624,752.00 72,105,399,209.24 supplies) Medical equipment 3,078,578,356.87 3,044,825,905.47 4,963,329,265.67 1,634,000,000.00 1,435,250,000.00 Total service delivery 40,192,544,283.57 47,045,455,780.96 58,698,448,487.75 64,522,828,274.24 74,188,326,844.96 Almost 80 percent of the strategy’s costs are in this second objective, which further reveals the curative approach to NCD prevention and treatment in Rwanda. Deliberate efforts are required to start shifting NCD services towards preventive programmes. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 89 STRATEGIC OBJECTIVE 3 Strengthen disease surveillance and research, alongside robust M&E systems, for evidence-based intervention This third objective includes research capacity strengthening, establishment of data and digital systems (purchase of computers and tablets) as well as STEPS and cost of NCD surveys (Table 9). Table 9: Surveillance, research and M&E (RWF) Actions 2021 2022 2023 2024 2025 Research capacity 7,612,391.70 building Data management 69,999,997.75 70,728,091.86 70,978,144.39 71,220,842.42 71,485,603.92 systems (computers) Digital connectivity of 2,807,020,006.00 2,836,216,789.00 2,846,243,967.00 2,855,976,228.00 2,866,593,240.00 medical records STEPS and NCD 456,870,000.00 - - - - economic cost surveys Total M&E, surveillance 3,341,502,395.45 2,906,944,880.86 2,917,222,111.39 2,927,197,070.42 2,938,078,843.92 and research STRATEGIC OBJECTIVE 4 Strengthen intersectoral coordination, advocacy and resource mobilisation for the prevention and control of NCDs Table 10: Intersectoral coordination costs (RWF) Actions 2021 2022 2023 2024 2025 Total intersectoral 6,691,991.58 6,761,597.30 6,785,502.29 6,808,704.19 6,834,015.36 coordination 90 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025

6.3.5 Health financing Total planned health expenditure In Table 11, total health expenditure (THE) is estimated at about RWF 488 billion in 2021, up from RWF 414 billion reported in 2017, and rising to RWF 569.6 billion in 2025. THE includes the entire health system with its different funding sources: public, donor agencies, households, and private health insurance. Table 11: Total planned health expenditure (RWF) 2021 2022 2024 2025 THE 487,797,500,000.00 509,701,000,000.00 548,792,280,000.00 569,592,000,000.00 THE, as % of GDP 4.8 4.7 4.5 4.4 ... real THE growth rate 3.4 3.4 3.4 3.4 (%) THE per capita 35,145.40 35,940.00 37,120.40 37,758.50 THE is expected to grow at a constant rate of 3.4 percent per annum which, as expected health expenditures, is slightly above the inflation rate. THE as a share of GDP, in-keeping with the national trend, declines from 4.8 percent in 2021 to 4.4 percent in 2025. This, however, should not be the case as literature suggests that a THE of about 5 percent of GDP is required to effectively finance UHC. The Rwandan Government is fully aware of this proportion of total health expenditure relative to GDP and should work toward meeting this target. Assessing capacity (financial space) to fund the projected costs (expenditure) Figure 11 suggests that with the current financing trajectory, the economy can sustain the planned NCD expenditure for the first two years (2021-2022), thereafter deficits begin to emerge. By 2025, planned expenditure (RWF 601.7 billion or USD 632 million) exceeds potential mobilisable funding (RWF 558 billion or USD 586 million) by about RWF 44 billion. With efficiency measures, including strategic purchasing and use of cost-effective technologies, the funding gap can be effectively addressed. As shown in Figure 12, NCD costs are estimated to account for about 18 percent of THE by 2025, up from about 13 percent in 2021. There is evidently poor tracking of NCD expenditures as previous analysis indicated that less than one percent of THE was spent on NCDs in 2017. Nevertheless, the projected 18 percent of THE for 2021 is modest, given the burden of NCDs in Rwanda and the status of NCD funding, which was assessed at less than two percent of THE. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 91 Figure 12: Planned expenditure vs financial space (USD millions) 800 600 Planned expenditure 400 Financial space 200 0 2021 2022 2023 2024 2025 Figure 13: NCD costs, % of planned expenditure 800 20% 600 15% Planned expenditure 400 10% Financial space 200 5% 0 0% 2021 2022 2023 2024 2025 92 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Potential impact of planned NCD expenditure The potential impact of planned health expenditure by disease category is represented by figures 13-16. Figure 14: CVD (all health states) 20,000 15,000 Healthy life years gained 10,000 Deaths averted 5,000 Incidence 0 2021 2022 2023 2024 2025 Figure 15: Diabetes (all health states) 400 300 Healthy life years gained 200 Deaths averted 100 Incidence 0 2021 2022 2023 2024 2025 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 93 Figure 16: Breast cancer (all health states) 1000 500 Healthy life years gained Deaths 0 averted 2021 2022 2023 2024 2025 Incidence - 500 - 1000 Figure 17: Colorectal cancer (all health states) 500 0 2021 2022 2023 2024 2025 Healthy life - 500 years gained Deaths - 1000 averted Incidence - 1500 - 2000 - 2500 There are improvements in healthy years lived and deaths averted in all disease categories. These improvements are however, limited for diabetes and colorectal cancer. Increases and decreases in incidence in diabetes and CVD respectively on one side and cancers on the other, may indicate differences in timely diagnosis and levels of exposure to specific risk factors, and may require a longer period of interventions than presented here, before incidence rates begin declining. 94 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025

6.4 Financing gap in NCD programming In order to estimate the NCD financing gap in Rwanda, the following data sources were consulted: MoH budget allocations to the NCD Division; operational costs from Butaro Cancer Centre of Excellence to estimate expenditure by Partners in Health (PIH), one of the main players in NCD prevention and control in Rwanda [59]; communication with development partners such as the Clinton Health Access Initiative (CHAI); and estimates of NCD expenditure from RSSB. Of the RWF 52 billion reimbursed by RSSB in 2019-2020, the assumption was made that 40 percent of this reimbursement was related to NCDs, in reflection of Rwanda’s disease burden and estimates by RSSB. Private health spending in Rwanda as a share of total health spending is 24.2 percent, so the same proportion was used to calculate private spending on NCDs (Table 12). In total, about USD 35.61 million was available for NCD programming in FY2019-20, contrasted with USD 47.42 million in planned expenditure. Table 12: Estimates of NCD funding from different sources Source 2019-20 (RWF) 2019-20 (USD) % MoH 650,000,000.00 670,103.09 1.9 Development partners 3,384,136,000.00 3,488,800.00 9.8 RSSB 20,800,000,000.00 22,819,528.25 64.1 Private sources 8,371,100,000.00 8,630,000.00 24.2 Total 33,205,236,000.00 35,608,431.34 100 Although THE is expected to grow at an average rate of 3.4 percent, expenditure on NCDs is conservatively assumed to be at a higher rate of 5 percent due to the size of the burden and its priority. It was also assumed that the proportions of funding from the different sources will not change significantly between 2000 and 2025 (Table 13). Table 13: Estimates of available revenue for NCD financing (USD) Total Source 2019 2020 2021 2022 2023 2024 2025 (%) MoH 670,103.09 703,608.25 738,788.66 775,728.09 814,514.50 855,240.22 898,002.23 1.9 Development 3,488,800.00 3,663,240.00 3,846,402.00 4,038,722.10 4,240,658.21 4,452,691.12 4,675,325.67 9.8 partners RSSB 22,819,528.25 23,960,504.66 25,158,529.90 26,416,456.39 27,737,279.21 29,124,143.17 30,580,350.33 64.1 Private 8,630,000.00 9,061,500.00 9,514,575.00 9,990,303.75 10,489,818.94 11,014,309.88 11,565,025.38 24.2 sources Total 35,610,450.34 37,390,972.86 39,260,521.50 41,223,547.58 43,284,724.96 45,448,961.20 47,721,409.27 100 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 95 Planned expenditure for NCDs range from USD 47.2 million in 2020 to USD 96.4 million in 2025. This leaves a funding gap ranging from USD 10 million in 2020 to USD 48.7 million in 2025 (Figure 17). An estimated revenue shortfall of RWF 44 billion or approximately USD 46 million by 2025 for the entire health sector was made based on fiscal space analysis, as opposed to financing trends, which would yield higher revenue shortfalls for the health sector. Figure 18: NCD financing needs 2020-2025 (USD million) 100 96,42 80 83,94 Planned 75,63 Expenditure 60 48,70 60,29 Available 52,92 38,49 Revenue 40 47,42 32,35 47,72 43,28 45,45 39,26 41,22 Revenue 37,39 Gap 19,07 20 13,66 10,03 0 2020 2021 2022 2023 2024 2025 Although the Rwandan government has put in place measures to address revenue shortfalls, especially for CBHI or mutuelle de sante, to achieve effective UHC for about 80 percent of the population, the adequacy of these measures (an additional RWF 6 billion or USD 6.2 million from the government budget and a 2.5 percent tax on profits from telecommunications) to meet the projected revenue shortfalls for the health system are unclear. To effectively address the funding shortfall for NCDs, available revenue needs to increase at an annual rate of 20.9 percent between 2021 and 2025. If each of the major stakeholders increases their funding by about 20.9 percent, as outlined in Table 14, then funding gaps can be effectively addressed. Table 14: Bridging the funding gap Source 2021 2022 2023 2024 2025 MoH 850,662.37 1,028,450.81 1,243,397.03 1,503,267.00 1,817,449.81 Development 4,428,857.16 5,354,488.31 6,473,576.36 7,826,553.82 9,462,303.57 partners RSSB 35,022,614.42 42,342,340.83 51,191,890.06 61,890,995.08 28,968,250.14 Private sources 13,825,280.50 16,714,764.13 20,208,149.83 24,431,653.15 11,435,302.32 Total (Available) 45,683,071.99 55,230,834.03 66,774,078.35 80,729,860.72 97,602,401.61 96 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 The MoH and development partners need to increase their budgetary allocations for NCDs, while the RSSB and private insurance actors should expand their benefit packages to include more NCD services. These proposals are feasible with advocacy and innovative resource mobilisation initiatives, and necessary to supplement currently available NCD resources.

6.5 Conclusion A heavy cost burden is associated with prevention and control of NCDs, particularly where treatment is concerned. Whilst it is important to meet the treatment needs of NCD patients, attention should focus on cost-effective preventive measures which have not only proven to be cheap, but also have high impact in reducing the disease burden. Such actions should be backed by an appropriate financing plan that improves the current financing arrangements, as well as endeavours to identify and develop new financing mechanisms, to meet the rising demand of health care especially those related to NCDs. The revenue shortfall is estimated at RWF 44 billion by 2025, but projections for government interventions to address the shortfalls yields about RWF 19.7 billion by 2025. 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8.1 Programmes FACILITIES Total Av. no. beds Av. bed occupancy rate % Av. outpatient visits / year Health Post 885 0 0 2,688,454.00 Health Centre 509 11,212.00 90 13,781,240.00 District Hospital 36 5,940.00 90 365,519.00 Provincial Hospital 4 691 90 226,956.00 Central Hospital 8 2,123.00 90 632,408.00 OPERATING COST Operating Amount Amount (not Non-electrical / costs as Amount (including including non-water operating percent of (USD) electrical and electrical and expenses as % of construction water) (USD) water) (USD) construction cost cost Facilities delivering interventions Health Post 0 240 0 0 0 Health Centre 0 1,200.00 0 0 0 District Hospital 0 42,000.00 0 0 0 Provincial Hospital 0 66,000.00 0 0 0 Central Hospital 0 84,000.00 0 0 0 Outpatient and inpatient costs Health District Provincial Health Centre National Referral Post Hospital Hospital Cost per outpatient visit (RWF) 2615.02 3708.09 7443.18 10554.43 6067.01 Cost per inpatient day (RWF) 0.00 6311.31 13401.78 17489.32 56794.56 102 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Training programmes Length of Cost per person to Trainees per Number of Type of training training (days) be trained (RWF) workshop trainers required Cervical and breast cancer screening and early 5 268,397.00 400 4 detection (nurses and doctors) Prostate and colorectal cancer screening (nurses and doctors) 2 219,677.20 120 2 LEEP training / cervical biopsy / colposcopy (doctors) 5 319,788.00 50 2 Biopsy and sample preservation and transportation procedures (GPs) 2 132,083.20 50 1 Breast ultrasound (GPs and nurses) 5 285,394.00 50 1 Basic cancer treatment (GPs and nurses) 5 617,344.36 55 1 Basic oncology skills - e-learning (all) 5 0 0 0 Comprehensive NCD care (+ palliative care) - Advanced (doctors) 5 285,794.00 100 2 Comprehensive NCD care - Basic - e-learning (nurses) 0 0 600 0 Comprehensive NCD, injury and disability care - Basic (nurses) 5 268,397.00 400 4 Advanced cardiac care (ECG, ECHOcardiography) (nurses and doctors) 5 319,788.00 25 1 Type 1 diabetes (nurses and doctors) 5 317,348.00 50 2 NCD screening and early detection (CHWs) 2 0 0 0 Basic life support GPs, nurses, anaesthetists, etc.) 5 316,948.00 50 1 Data management and reporting / forecasting and supply chain 5 316,948.00 50 1 Advanced /specialised trainings (2 Masters) 1 9,518,000.00 1 0 Training-of-Trainers - Palliative care and pain management 5 308,849.12 0 1 e-learning workshop 3 142,300.00 10 11 Type of Activity (RWF) 2021 2022 2023 2024 2025 Workshop for school based NCD / injuries curriculum development 18,292,196.85 0 0 0 0 Workshop to define research agenda 2,300,196.02 0 0 0 0 Workshop for research capacity building 5,312,195.68 0 0 0 0 Workshop for preservice NCDs / injuries integration curriculum 5,692,201.83 0 0 0 0 Workshop to review NCDs / injuries guidelines and protocols (2025) 5,312,195.68 0 0 0 0 NCD annual conference 5,561,995.59 5,619,847.82 5,639,716.27 5,659,000.34 5,680,037.52 Total Support Activities 42,470,981.65 5,619,847.82 5,639,716.27 5,659,000.34 5,680,037.52 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 103

8.2 Intervention coverage Baseline coverage Target coverage used from impact to assess impact and module (2020) intervention costs (2025) NCDs CVD and diabetes Screening for risk of CVD / diabetes 10 40 Follow-up care for those at low risk of CVD / diabetes (absolute risk: 10-20%) 10 20 Treatment for those with very high cholesterol but low absolute risk of CVD / diabetes (< 20%) 10 25 Treatment for those with high blood pressure but low absolute risk of CVD / diabetes (< 20%) 10 25 Treatment for those with absolute risk of CVD / diabetes 20-30% 10 25 Treatment for those with high absolute risk of CVD / diabetes (>30%) 5 20 Treatment of new cases of acute myocardial infarction (AMI) with aspirin 5 20 Treatment of cases with established ischaemic heart disease (IHD) 5 30 Treatment for those with established cerebrovascular disease and post stroke 5 30 Treatment of cases with rheumatic heart disease (with benzathine penicillin) 5 10 Standard glycaemic control 20 30 Intensive glycaemic control 5 10 Retinopathy screening and photocoagulation 20 30 Neuropathy screening and preventive foot care 0 0 Elimination of industrial trans fats 0 0 Breast cancer Basic breast cancer awareness 30 60 Screening: Clinical breast exam 10 50 Screening: Mammography 1.5 5 Diagnosis: Screened with clinical breast exam 40 60 Diagnosis: Screened with mammogram 10 20 Diagnosis without screening for breast cancer 50 55 Breast cancer treatment: Stage 1 10 20 Breast cancer treatment: Stage 2 10 30 Breast cancer treatment: Stage 3 20 30 Breast cancer treatment: Stage 4 70 75 Trastuzamab 5 20 Post-treatment surveillance for breast cancer patients 30 40 Basic palliative care for breast cancer 30 40 Extended palliative care for breast cancer 30 40 Breast cancer ultrasound 0 0 Cancers 104 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 HPV DNA test 10 20 Visual inspection with acetic acid (VIA) 15 30 Papanicolaou test (Pap smear) 0 0 HPV DNA + VIA 15 30 HPV DNA + Pap smear 0 0 Biopsy and histopathology 20 30 Cryotherapy 10 15 Loop Electrosurgical Excision Procedure (LEEP) 10 15 Cervical cancer treatment: Stage I 10 20 Cervical cancer treatment: Stage II 10 30 Cervical cancer treatment: Stage III 20 30 Cervical cancer treatment: Stage IV 70 75 Post treatment surveillance for cervical cancer 30 40 Basic palliative care for cervical cancer 30 40 Extended palliative care for cervical cancer 30 40 Screening: Faecal immunochemical test 0 5 Screening: Faecal occult blood testing 0 5 Screening: Sigmoidoscopy 0 5 Screening: Colonoscopy 0.5 1.5 Diagnosis for colorectal cancer screened with FIT 0.5 5 Diagnosis for colorectal cancer screened with FOBT 0.5 1.5 Diagnosis for colorectal cancer screened with sigmoidoscopy 0 5 Diagnosis without screening for colorectal cancer (symptom based) 5 10 Colorectal cancer treatment: Stage I 10 20 Colorectal cancer treatment: Stage II 10 30 Colorectal cancer treatment: Stage III 20 30 Colorectal cancer treatment: Stage IV 70 75 Post treatment surveillance for colorectal cancer 20 40 Basic palliative care for colorectal cancer 30 40 Extended palliative care for colorectal cancer 30 40 Dental cleaning and preventive care 10 20 Oral cancer treatment 30 40 Prostate cancer 30 40 Respiratory disease Asthma: Inhaled short acting beta agonist for intermittent asthma 5 20 Asthma: Low dose inhaled beclometasone + SABA 5 20 Asthma: High dose inhaled beclometasone + SABA 5 20 Asthma: Theophylline + High dose inhaled beclometasone + SABA 5 10 Asthma: Oral Prednisolone + Theophylline + High dose inhaled beclometasone + SABA 10 20 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 105 COPD: Smoking cessation 5 10 COPD: Inhaled salbutamol 5 10 COPD: Low-dose oral theophylline 10 20 COPD: Ipratropium inhaler 10 20 COPD: Exacerbation treatment with antibiotics 5 20 COPD: Exacerbation treatment with oral prednisolone 5 10 COPD: Exacerbation treatment with oxygen 20 30 Emergency care Average annual emergency care needs 0.22 20 Risk Factors Offer to help quit tobacco use: Brief intervention 10 40 Screening and brief intervention for hazardous and harmful alcohol use 10 40 Physical inactivity: Brief advice as part of routine care 10 40 Policy interventions - Under Programme Costing Tobacco: Monitor tobacco use/prevention policies 20 70 Tobacco: Protect people from tobacco smoke 0 50 Tobacco: Offer to help quit tobacco use: mCessation 50 70 Tobacco: Warn about danger: Warning labels 50 70 Tobacco: Warn about danger: Mass media campaign 50 70 Tobacco: Enforce bans on tobacco advertising 50 80 Tobacco: Enforce youth access restriction 20 50 Tobacco: Raise taxes on tobacco 90 100 Tobacco: Plain packaging of tobacco products 0 50 Hazardous alcohol use: Enforce restrictions on availability of retailed alcohol 0 85 Hazardous alcohol use: Enforce restrictions on alcohol advertising 0 85 Hazardous alcohol use: Enforce drunk driving laws (sobriety checkpoints) 20 50 Hazardous alcohol use: Raise taxes on alcoholic beverages 20 85 Physical inactivity: Awareness campaigns to encourage increased physical activity 0 50 Sodium: Surveillance 0 50 Sodium: Harness industry for reformulation 0 50 Sodium: Adopt standards: Front of pack labelling 0 50 Sodium: Adopt standards: Strategies to combat misleading marketing 0 50 Sodium: Knowledge: Education and communication 0 50 Sodium: Environment: Salt reduction strategies in community-based eating spaces 0 50 Reducing obesity: Complete elimination of industrial trans fats 0 50 Reducing obesity: Replace saturated fats with unsaturated fats through reformulation, labelling, and fiscal policy 0 50 Reducing obesity: Reduce sugar consumption through taxation on sugar-sweetened beverages 0 50 106 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 Publication details Published by: Non-Communicable Disease Division, Rwanda Biomedical Centre, Ministry of Health, Rwanda With technical support from: The Defeat-NCD Partnership at the United Nations Institute for Training and Research Publication date: November 2020 National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda | July 2020 – June 2025 107 www.moh.gov.rw I www.rbc.gov.rw