Integrating Population, Health, and Environment in Rwanda

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P2/.(: Br.*+ 2.6% If the current annual population growth rate persists, Rwanda 9s population is projected to reach 14.6 million by 2025. An integrated population- health-environment (PHE) approach to development recognizes the interconnections between people and their environment and supports cross-sectoral collaboration and coordination. by Melissa ThaxTon february 2009 IntegratIng PoPulation, HealtH, and environment in rwanda The last decade in Rwanda 9s history has been one o7 transition and rebirth.

Ten years ago, the country was emerging 7rom several years o7 stri7e and civil con ict; in 2009, urban and rural areas are energized with the promise o7 steadily improving economic, social, and health conditions. Despite this impressive trans7ormation, Rwanda 7aces various challenges, many related to the complex relationships between population trends, poverty, and environmental conditions. Rapid population growth and the resultant dwindling landholdings, 7or example, have pushed more people onto landscapes poorly suited 7or agriculture, grazing, and settlement, such as steep hillsides and urban watersheds.

As a result, an increasing number o7 households are vulnerable to 7ood shortages and water scarcity and are more susceptible to disease and poor health. Thus, continued improvement in the quality o7 li7e o7 Rwanda 9s citizens depends in large part on fnding innovative and integrated ... more. less.

solutions to complex population, health, and environment problems. Fortunately, the links between population, health, and environment are now largely recognized by policymakers in Rwanda, especially since the end o7 the transition period in 2003. 1 Indeed, almost all o7 Rwanda 9s national-level policies acknowledge the need 7or cross-sectoral collaboration in order to e77ectively address the complex problems and issues currently 7acing the country. In practice, however, institutional coordination and integrated planning and program implementation are happening slowly and sporadically, with 7ew projects and programs to date success7ully integrating cross-sector initiatives. 2 Most projects and programs 4whether implemented by the government or NGOs, at a national scale or at the community level 4continue to 7ollow the traditional sectoral approach, aligned with government services and institutional structures. Yet a growing body o7 evidence shows that in many cases, desired programmatic outcomes can be achieved with greater cost-e77ectiveness, increased programmatic and administrative e77iciencies, and higher rates o7 community participation and support by employing an integrated, holistic approach to development. 3 An assessment o7 the overall cstate o7 integration d was recently undertaken by an interdisciplinary team led by the Centre 7or Resource Analysis in Kigali to explore in RWANDA KENYA UGANDA DEM. REP. OF CONGO BURUNDI TANZANIA RWANDA Ruhengeri Kakitumba Gabiro Kibuye Kigali A nurse administers anti-helminth drugs to students in Nyamagabe district in the Southern Province o7 Rwanda to combat intestinal parasites. PoPulation RefeRence BuReau Pulcherie Mukangwije, FHI, 2008 more detail population-health-environment interactions and the opportunities 7or and challenges o7 cross- sectoral collaboration and integrated programming in Rwanda (see Box 1, page 2). A Population, Health, and Environment Approach to Development An integrated population-health-environment (PHE) approach to development recognizes the interconnections between people and their environment and supports cross-sectoral collaboration and coordination. As its name suggests, the approach places particular emphasis on the population, health, and environment sectors. However, the underlying philosophy is 7undamentally one o7 integration. It can accommodate other sectors, such as agriculture and education, and be success7ully applied to achieve a range o7 development goals 7rom poverty reduction to 7ood security. In Rwanda, the importance o7 addressing development issues in an integrated 7ashion is re ected in the recently implemented (2006) Poverty-Environment Initiative (PEI), supported jointly by the United Nations Development Programme (UNDP) and the UN www.p 6b. 4 6g integRating PoPulation, HealtH, and enviRonment in Rwanda 2 Box 1 Rw&1d& P2p7/&t.21, h*&/t-, &1d e1v.r21m*1t (Phe) a55*55m*1t This policy brie. is based on the Rwanda PHE Assessment written by Charles Twesigye-Bakwatsa o. the Centre .or Resource Analysis, with assistance .rom members o. the Rwanda PHE Assessment team. PRB coordinated a comparative study o. population, health, and environment integration in East A.rica. Teams .rom Ethiopia, Kenya, Rwanda, Tanzania, and Uganda assessed the state o. PHE integration in their respective countries, including identi.ying relevant stakeholders; assessing the policy environment .or cross-sectoral collaboration; highlighting the most salient population, health, and environment issues; and describing the current state o. integration among projects, programs, and policies. The methods used .or this assessment include a review o. relevant policies, laws, and project documents; key in.ormant interviews; and eld visits to case study sites. The Rwanda PHE Assessment was made possible with .unding .rom the U.S. Agency .or International Development (USAID). Environment Programme (UNEP). In the frst phase o7 this initiative, an integrated ecosystem assessment (IEA) was conducted in Bugesera district in southeastern Rwanda between 2006 and 2007. The IEA concluded that population pressure and poverty were among the main drivers o7 declining availability o7 and access to ecosystem services such as clean water, 7ood, and energy, and that these shortages have had a pro7ound e77ect on Bugesera residents 9 health and well-being. The IEA also concluded that integrated approaches would be more e77ective in ecosystem rehabilitation and in reversing the negative impacts o7 environmental changes on human well-being. 4 Rwanda 9s Development Frameworks Vision 2020 Rwanda 9s Vision 2020 is the country 9s overarching national planning and policy 7ramework into which other strategies, plans, programs, and policies are meant to ft. The global vision o7 the government o7 Rwanda as set out in Vision 2020 is to guarantee the well-being o7 its population by increasing productivity and reducing poverty within an environment o7 good governance. Adopted in 2000, Vision 2020 highlights population-health- environment interactions and recognizes that the country 9s problems cannot be tackled in isolation: cRwanda 9s high population growth is one o7 the major causes o7 the depletion o7 natural resources and the subsequent poverty and hunger. And poverty remains a major cause o7 poor health and vice versa & Future and current population policies should go hand in hand with strategies to overcome problems in the health sector. Family planning is crucial 7or reducing birth rates & and bringing population and [the country 9s] natural resources into balance. d 5 MillenniuM DeVeloPMenT Goals In September 2000, Rwanda became a signatory to the United Nations Millennium Declaration, pledging to achieve the Millennium Development Goals (MDGs) by the target date o7 2015. 6 Re ecting its commitment to the global partnership to reduce extreme poverty, the government o7 Rwanda has aligned its development policies and programs with MDG targets. So 7ar, Rwanda has made noteworthy progress toward meeting two o7 the eight MDGs: achieving universal primary education (Goal 2), with 96 percent o7 school-age children enrolled in primary school (girls 9 enrollment has surpassed that o7 boys 9); and promoting gender equality and empowerment o7 women (Goal 3), with 50 percent o7 seats in parliament held by women. econoMic DeVeloPMenT anD PoVeRTy ReDucTion sTRaTeGy (2008-2012) Rwanda 9s Economic Development and Poverty Reduction Strategy (EDPRS) provides a medium-term 7ramework 7or achieving the country 9s long-term development aspirations as embodied in Vision 2020 and the MDGs 4namely, economic growth, poverty reduction, and human development. Intended as an operational tool, the EDPRS is supported through detailed sectoral strategic plans and is the country 9s main mechanism 7or mobilizing and allocating public expenditure resources. The EDPRS promotes three agship programs: Sustainable Growth 7or Jobs and Exports; Vision 2020 Umurenge ; 7 and Good Governance. Although emphasis is squarely placed on promoting economic growth in Rwanda, the strategy also includes targets 7or e77ective environmental management, slowing population growth, and improving health. Population Trends and Policies Rwanda 9s population growth over the last 7our decades has been unprecedented 47rom approximately 2.6 million in 1960 to 8.2 million in 2002 and 9.6 million by mid-2008. I7 the current annual population growth rate o7 2.6 percent persists, the country 9s population is projected to reach 14.6 million by 2025. 8 Though Rwanda 9s total population is small in comparison to most other countries in A7rica, its population density o7 365 people per square 3 integRating PoPulation, HealtH, and enviRonment in Rwanda www.p 6b. 4 6g kilometer is the highest on the continent and is o7ten cited as a contributing 7actor to poverty and environmental degradation. Women 9s health status is compromised by early and repeated pregnancies and inadequate (though improving) 7amily planning and maternal health care services, especially in rural areas. High 7ertility 4li7etime births per woman in Rwanda is 5.5 4has implications 7or both in7ant and maternal morbidity and mortality. 9 Data show that 70 percent o7 births take place without skilled medical assistance and a low utilization o7 basic obstetric care. 10 The maternal mortality ratio remains high at 750 deaths per 100,000 live births, and the in7ant mortality rate is 62 deaths per 1,000 live births. 11 Population structure and distribution in Rwanda have been pro7oundly reshaped by the civil war and genocide in the 1990s, which killed up to a million people, le7t thousands o7 orphans and widows, and signifcantly changed traditional 7amily structures (see Box 2). There are now concerns within the Rwandan government and among development partners that 4should the current population growth rate continue 4economic growth, political stability, and ongoing recovery and reconciliation will be undermined. 12 Although many o7 Rwanda 9s population and health indicators are still unacceptably poor, there has been some noteworthy improvement in reproductive health service delivery and outcomes since the a7termath o7 the war and genocide (see table, page 4). For example, in 1994, contraceptive prevalence stood at just 4 percent; by 2005, Box 2 Rw&1d& 95 G*12(.d* 2+ 1994: it5 l*g&(: &1d t-* R2&d t2 R*(2v*r: &1d R*(21(./.&t.21 T he civil war in Rwanda, which began in 1990, and the subsequent episode o. genocide in 1994, le.t a horri c legacy o. poverty, ill-health, and human devastation: displacement o. millions o. people, a signi cant reduction in the number o. adult men, a large number o. orphans, many households without permanent shelter, a reduction in small-scale .arming, an increase in the prevalence o. AIDS, the loss o. human resources and in.rastructure, and the emigration o. thousands o. Rwandans to the Democratic Republic o. Congo. The Rwandan government, with support .rom the international community, has made progress in the di. cult process o. moving .rom emergency to long-term development. About 3.5 million Rwandan re.ugees have been repatriated and resettled. A Unity and Reconciliation Commission was established to consolidate the government policy o. redressing the legacy o. divisive politics that has been a prominent .eature o. Rwanda .or many decades. Through a Genocide Survivors Fund, the government provides support in education, shelter, health, and income- generating activities to the most vulnerable survivors. Furthermore, traditional justice systems were established to .acilitate local trials o. genocide participants. Economic recovery has been consistent since 1994 when real gross domestic product (GDP) declined by 50 percent and infation stood at 65 percent. The average rate o. expected annual growth is projected at 8 percent over the next 15 years, and the government has set a goal o. raising the per capita income .rom $370 in 2007 to $900 by 2020. On the political .ront, the government o. Rwanda has made progress in maintaining the inclusiveness o. the broad-based government. A policy o. decentralization has been initiated to involve people in local communities in decisionmaking, allowing the Rwandan people to play an active role in the trans.ormation o. their society .rom one o. devastation and despair to one o. peace and prosperity. n$( b: The male/7emale ratio in Rwanda is 47/53; it is estimated that there are 1.26 million orphans in Rwanda; out o7 an estimated 250,000 women who were raped during the civil stri7e o7 the 1990s, at least 175,000 were reported to have been in7ected with HIV. S$)r 9 bs: Data are taken 7rom the government o7 Rwanda, accessed online at www.gov.rw, on Sept. 15, 2008; Rwanda PHE Assessment; and Judy Manning, Kamden Ho77man, and Jessica Forrest, Rwanda 2008 Community Health Needs Assessment (CHNA) (Washington, DC: USAID, 2008). Destination Nyungwe Project sta77, teachers, and parents demonstrate proper hand-washing and hygiene practices at a primary school in Nyamasheke district in the Western Province o7 Rwanda. Pulcherie Mukangwije, Family Health International, 2008 www.p 6b. 4 6g integRating PoPulation, HealtH, and enviRonment in Rwanda 4 it had increased to 10 percent. Results 7rom a 2008 survey reveal that contraceptive use has increased again to 27 percent o7 married women o7 reproductive age. The survey also shows a marked decline in the in7ant morality rate 47rom 86 deaths per 1,000 live births in 2005 to 62 in 2008. 13 The National O7fce o7 Population (ONAPO) was created in 1981 to address broad sociodemographic issues that had become a challenge to Rwanda 9s development. One o7 the major results o7 this program was the 7ormulation o7 the frst National Population Policy (1990). The policy was later re7ormulated, and the current National Population Policy (2003) envisages using an integrated approach to addressing population growth by improving health and survival o7 children and women as incentives 7or smaller 7amilies; providing education and employment; and building an institutional structure that integrates gender, governance, health care, environment, and nutrition. The population policy implementation, however, su77ered setbacks when ONAPO was phased out in 2003 to avoid duplication o7 the Health Ministry 9s own e77orts in providing 7amily planning and reproductive health services. A7ter the closure o7 ONAPO, responsibility 7or population policy implementation was trans7erred PHE IndIcator around 2000 2005 2008 Population size (millions) 8.2 (2002) a 9.2 b 9.6 Population growth rate (% per year) 2.4 b 2.6 4 Population density (per sq. km.) 321 (2002) 349 b 365 Li.etime birth per woman 5.8 6.1 5.5 Percent o. married women using contraception (modern methods) 4 10 27 In.ant deaths per 1,000 live births 107 86 62 Maternal mortality (deaths per 100,000 live births) 1,071 750 4 Urbanization (% urban o. total pop.) 4 17 21 HIV prevalence (% o. total pop.) 4.3 (2001) c 3 4 Percent rural population with access to improved water source 4 22 4 4 Not available. S$)r 9 bs: Rwanda Demographic and Health Surveys 2000 and 2005 and Interim Demographic and Health Survey 2008, except where noted. a 2002 Rwanda General Population and Housing Census. b UN Population Division, World Population Prospects, online data (http://esa.un.org/unpp/ index.asp, accessed Jan. 21, 2009), c UNAIDS/WHO, Epidemiological Fact Sheet on HIV and AIDS, 2008 Update, Rwanda. P cp! a 5t 9 c b 5 bd H 7 5 ath T e 7 bds 9 b rw 5 bd 5, 2000 t c 2008 to the Ministry o7 Health. Although the closure o7 ONAPO has streamlined the coordination and implementation o7 reproductive health and 7amily planning in Rwanda, it has also narrowed the spectrum o7 cross-cutting population issues such as migration and urbanization on the policy agenda. 14 A revision o7 the National Population Policy is currently ongoing and being coordinated by the Department o7 Development Planning in the Ministry o7 Finance and Economic Planning. Health Status and Policy Responses According to the National Health Sector Policy (2005), malaria and AIDS are the two biggest health problems in Rwanda, and accordingly, the prevention, treatment, and control o7 the two diseases are the country 9s best-7unded health care programs. Access to sa7e water and sanitation are also important health issues in Rwanda and have received increased attention in the past several years. MalaRia Malaria is one o7 the leading causes o7 outpatient attendance (about 50 percent o7 all health center visits are due to malaria) and is the primary cause o7 morbidity in all districts o7 Rwanda. Since 2000, close to 1 million cases o7 malaria have been recorded each year countrywide, with more than hal7 o7 both hospital visits and deaths occurring among children under age 5. Malaria is also a signifcant health risk 7or pregnant women and their unborn children, particularly frst-time mothers and women with HIV. 15 The increase in the malaria incidence rate 7rom 3.5 percent in 1982 to 48 percent in 2003 is linked to many population, health, and environment 7actors. Among these are changes in disease resistance to treatments; changes in household spraying policies and fnancing; greater population density and population movements; changes in climatic conditions (rain7all, temperature); and growth o7 human and economic activities such as rice 7arming, brick-making, and mining that increase breeding areas 7or mosquitoes. To combat malaria in Rwanda, the National Malaria Control Programme is being implemented with support 7rom various donors, including the President 9s Malaria Initiative (PMI) o7 the U.S. government. The PMI supports 7our key areas: indoor residual spraying o7 insecticides in homes; provision o7 treated mosquito bed nets; provision o7 antimalarial drugs; and treatment to prevent malaria in pregnant women. The Malaria Control Programme is recognized as one o7 the 7ew programs in Rwanda that has benefted 7rom e77ective cross- sectoral collaboration. 16 Success7ul program integration is attributed to fve key 7actors: early recognition by top-level decisionmakers within the Ministry o7 Health o7 the cross-cutting nature o7 malaria to include economic, gender, and environmental considerations; substantial capacity-building support 7rom the World Health Organization (WHO), USAID, and other agencies; a comprehensive 5 integRating PoPulation, HealtH, and enviRonment in Rwanda www.p 6b. 4 6g multisectoral malaria control policy and strategy implementation; use7ul policy-oriented research; and e77ective application o7 lessons learned and good practices 7rom other health and malaria control initiatives in the region. 17 Furthermore, the decentralization process 4which has mandated greater delegation o7 responsibilities to local authorities, especially since 2005 4has 7acilitated ownership and active involvement o7 health care programs by local political leaders and other nonhealth personnel. The increased participation o7 local leaders and other stakeholders outside the health 7ield has enhanced community mobilization and service delivery, which are important requisites 7or success7ul implementation o7 multisector programs like malaria control. hiV/aiDs HIV prevalence in Rwanda was estimated at 3 percent in 2005, down 7rom 4 percent in 2001 and 7 percent in 1995. 18 In7ection rates vary by sex (2.3 percent among males, 3.6 percent among 7emales) and location (7.3 percent in urban areas and 2.2 percent in rural areas). 19 Even with the positive gains made in reducing HIV/AIDS in Rwanda, AIDS remains a leading cause o7 death in the country, second only to malaria. With 7unding 7rom the U.S. President 9s Emergency Plan 7or AIDS Relie7 (PEPFAR), the World Bank-7unded Multi-Sectoral AIDS Programme (MAP), and bilateral agencies, Rwanda has increased its HIV/AIDS prevention, care, and treatment e77orts to include volunteer counseling and testing (VCT) services; support to orphans and other vulnerable children (OVC); and the provision o7 anti- retroviral prophylaxis to HIV-positive men and women, including HIV-positive pregnant women 7or prevention o7 mother-to-child transmission (PMTCT). 20 The complex links between HIV/AIDS and the environment are just beginning to be understood. 21 However, emerging evidence suggests that AIDS can lead to an accelerated rate o7 resource extraction when people turn to natural resources to replace household income lost a7ter an income-earning 7amily member dies 7rom an AIDS-related illness or is too sick to work. 22 The result is o7ten increased resource dependence and intensity o7 use. Furthermore, HIV/AIDS can lead to loss o7 trained and experienced people within the conservation community, and may also undermine e77orts in community-based natural resource management. WaTeR anD saniTaTion Rwanda 9s urban population share increased 7rom just 5 percent in 1995 to 17 percent a decade later. The rate o7 urbanization is accelerating and Rwanda 9s urban population is expected to reach 30 percent by 2020. 23 Environmental problems are serious in Rwanda 9s burgeoning, unplanned, o7ten congested urban centers, especially Kigali. For example, only 15 percent o7 sewage is managed by municipal authorities, and about 55 percent o7 urban households have no access to solid waste disposal 7acilities. Cholera, dysentery, and other water-borne diseases are common throughout Rwanda. Although 92 percent o7 the country 9s population reported having access to a latrine, only 38 percent meet acceptable hygiene standards. In hilly terrain, shallow pit latrines, even when properly used, pose a pollution threat to domestic water sources. 24 Between 2000 and 2005, the percentage o7 people with access to an improved water source remained constant at just 64 percent, and access actually declined in Kigali, 7rom 88 percent to 82 percent. 25 In rural areas, expanding agricultural activity has destroyed watersheds and increased soil erosion 4causing water runo77 and sedimentation and reducing the volume o7 water owing downstream. In some urban areas, the rising cost o7 water, which is o7ten delivered by tanker trucks, is becoming prohibitive 7or many urban poor. Though much work remains to be done to improve the health and well-being o7 Rwandans, the health sector is poised is make signifcant progress in achieving its health goals. Along with the education sector, the health sector has made the biggest inroads to success7ully integrating its programs across sectors in accordance with Health Ministry principles: acceptability and quality o7 health care, e77ectiveness and e7fciency, intersectoral coordination, community participation, decentralization, and integration. The Health Sector Policy recognizes that cactions in the health sector will have a more sustainable impact i7 they are integrated and 7undamentally incorporated into the national development programs. Intersectoral consultation and collaboration with ministerial partners is essential in the implementation o7 major health strategies. d 26 Environment Rwanda is endowed with a diversity o7 ecosystems, ranging 7rom moist steep mountains to at dry plains. Almost all valleys are wet with natural sources o7 water and the soils have continued to support at least two growing seasons o7 7ood and cash crops. But Rwanda 9s mountainous topography and growing human population have resulted in increasingly severe environmental degradation: soil erosion 7rom cultivation o7 steep slopes; pollution and sedimentation o7 water sources; and loss o7 7orests, protected areas, and biodiversity to new human settlements. Rwanda has three national parks: Akagera National Park (ANP) in the east, Nyungwe National Park (NNP) in the southwest, and Environmental problems are serious in Rwanda 9s burgeoning, unplanned, often congested urban centers, especially Kigali. www.p 6b. 4 6g integRating PoPulation, HealtH, and enviRonment in Rwanda 6 Volcanoes National Park (VNP) in the north. Natural 7orests now cover only a small part (20 percent) o7 Rwanda 9s total land sur7ace, but have high biological diversity, with several species endemic to the 7orests. 27 Natural resource management and biodiversity conservation are extremely challenging in the 7ace o7 high population growth, low levels o7 literacy, and extreme poverty. In Rwanda, these challenges have been compounded by the 1990s war and genocide, which led to the loss o7 approximately 190,000 hectares o7 7orests and protected areas, as well as much o7 Rwanda 9s cadre o7 valuable environmental pro7essionals and advocates. Since 1994, the settlement and resettlement o7 displaced persons and returning re7ugees has reduced the coverage o7 Rwanda 9s protected areas even 7urther. In 1993, protected areas covered 15 percent o7 Rwanda 9s total land area, but by 2006, this had shrunk to 8 percent. 28 Two-thirds o7 the Akagera National Park, 7or example, was excised 7or resettlement by Rwandans who returned to the country a7ter decades o7 exile. What remains o7 the 2,000 hectares o7 Gishwati Forest Reserve is now almost entirely settled. Environmental governance, until recently, has been very weak. Only a7ter the ratifcation o7 Rwanda 9s Constitution in 2003 were the main documents and governing bodies established 7or the environmental sector. They were the National Environmental Policy (2003), the Organic Law on Conservation and Protection o7 Environment in Rwanda (2003), and the Rwanda Environmental Management Authority (REMA) (2006). The National Environment Policy recognizes the strong links between population, health, poverty, and environment and contains policy statements and strategic options with regard to population growth and sustainable land-use management. Among its stated objectives is the improvement o7 cthe health o7 the Rwandan people and promotion o7 their socioeconomic development through the sustainable management and utilization o7 natural resources and the environment. d However, policy and legislative gaps remain. For example, there is no policy on wildli7e management and conservation outside protected areas, and con icts with communities in and around protected areas persist without e77ective policy guidance on how to deal with them. Perhaps more signifcant, REMA has been overwhelmed by the requirements 7or human resources, fnances, and coordination 7or integrating environmental concerns at all levels o7 government and across sectors. Cross-Sectoral Collaboration in Rwanda: PHE Integration at the Policy Level Most o7 Rwanda 9s existing national policies and strategies embrace the spirit o7 cross-sectoral collaboration and coordination. However, institutional capacity is not yet adequate to turn policy intentions into integrated initiatives at the district and community levels (see Box 3). In addition to strengthening capacity, integration will require harmonization o7 institutional visions and goals, work cultures and ethical norms. Public sector re7orms that enhance decentralization are underway in Rwanda and allow 7or greater cross-sector integration through local government planning and budgeting. Territorial re7orm policy in the country aims to strengthen decentralized governance 7or the beneft o7 local populations and to streamline development e77orts to be more e77ective, e7fcient, and responsive to local communities. Within this newly decentralized government structure and under the auspices o7 Rwanda 9s Vision 2020 and EDPRS, there are emerging opportunities 7or PHE integration. For example, the Common Development Fund (CDF), which was established to support implementation o7 local development projects under decentralization, also provides a 7ramework 7or encouraging integrated development, especially in rural in7rastructure such as roads, education and health care 7acilities, terracing 7or soil erosion control, re7orestation, and water supply 7acilities, among others. Also noteworthy in the shi7t toward cross-sector integration in Rwanda is the adoption o7 a sector-wide approach (SWAP) to planning, resource mobilization, and implementation, in contrast to the traditional institution-specifc 7rameworks used in the past. It has progressed well in health and education and is emerging in lands and agricultural sectors. In conjunction with SWAP, a comprehensive monitoring and evaluation 7ramework has been developed that brings together all sectors to assist monitoring and evaluation o7 the progress toward attaining EDPRS targets. Finally, the establishment o7 two new policy research institutions is encouraging: The Rwanda Research, Science, and Technology Council and the Institute 7or Policy Analysis and Research (RIPAR) promise to enhance evidence-based policy 7ormulation and help raise fnancial resources 7or interdisciplinary research. Within this newly decentralized government structure and under the auspices of Rwanda 9s Vision 2020 and EDPRS, there are emerging opportunities for PHE integration. 7 integRating PoPulation, HealtH, and enviRonment in Rwanda www.p 6b. 4 6g Integrated Projects and Approaches in Rwanda: PHE at the Community Level The Rwanda PHE assessment 7ound that most policymakers and development partners in the country now pre7er a coordinated multisectoral approach to development at the policy level. A 2005 review o7 integrated population-health-environment programs in the Philippines and Madagascar o77ers some evidence that this approach has community-level programmatic benefts as well. The review concluded that, very o7ten, integrated PHE programs add value beyond their single-sector components and are more programmatically e7fcient. 29 One o7 the added benefts o7 integrated programming 4according to the results o7 operational research and the views o7 NGO practitioners 4is the potential 7or reaching larger numbers o7 benefciaries. PHE programs have been especially e77ective at increasing the participation o7 women in conservation activities and the participation o7 men and youth in 7amily planning and health activities. Additional benefts o7 integrated programs documented through operational research include: reduced operating expenses; avoidance o7 duplicated e77ort; strengthened cross-sectoral coordination at the local level; greater community goodwill and trust; and increased women 9s status and sel7-perception in project areas, especially when programs include microcredit or other livelihood activities. Even with all the benefts associated with integrated programming, many challenges exist in implementing integrated approaches. Donors continue to in uence programming by heavily shaping the thematic scope, content, and location o7 many projects. Although recent re7orms in Rwanda have expanded the 7ramework 7or cooperation between donor agencies and local authorities, the local capacity to determine and in uence program design is still limited. In addition, insu7fcient human resources and institutional capacities have constrained integrated PHE initiatives. Monitoring and evaluation (M&E) has been one area in particular that has been criticized 7or being defcient in PHE programs. The complexity o7 integrated programs that work across sectors, o7ten with multiple implementing partners and di77ering M&E systems, can make it di7fcult to track impact or properly attribute impact to a particular project or set o7 interventions. 30 Despite these challenges, several integrated projects in Rwanda have brought positive change to people and the environment in a relatively short amount o7 time. The 7ollowing 7our projects are among the success stories. DesTinaTion nyunGWe PRojecT: PRofiTaBle ecoTouRisM ThRouGh iMPRoVeD BioDiVeRsiTy conseRVaTion in RWanDa The Destination Nyungwe Project (DNP) has implemented an integrated approach to conservation o7 the Nyungwe National Park (NNP) by linking ecotourism, health, and biodiversity conservation Box 3 K*: f&(t2r5 +2r s7((*55+7/ Pr2gr&m i1t*gr&t.21 &1d M7/t.5*(t2r&/ c2//&b2r&t.21 Rwanda 9s Malaria Control Programme is considered a model .or success.ul program integration and multisectoral collaboration. The programme highlights ve critical .actors .or achieving integration: Support .or multisectoral collaboration .rom top-level " decisionmakers. A comprehensive policy and well-developed strategy " .or program implementation. Strong institutional capacity. " Relevant interdisciplinary and policy-oriented research. " E..ective application o. lessons and best practices. " interventions. 31 The project seeks to protect biodiversity in the Nyungwe protected ecosystem 4which is threatened by human encroachment, illegal wood and honey gathering activities, and mining operations 4by strengthening protected area management, mainstreaming environmental issues into district development plans, and promoting environmental awareness and stewardship among the communities surrounding the park. The main strategy 7or achieving these goals is through development o7 ecotourism as a means o7 providing an economic beneft 7rom conservation to nearby communities. At the same time, the project is responding to the priorities o7 local communities by improving health care services (including 7amily planning and maternal and child health services), developing nonagricultural employment opportunities, and strengthening production and marketing o7 7ood crops and cra7ts that can be sold to tourist hotels and marketplaces. Although the DNP is both small (activities are carried out in just three sites) and new (activities began in 2006), the project has made some notable achievements in a short two-year time period: DNP sta77 participated in several district planning meetings, convincing " local authorities in Nyamagabe and Nyamasheke to include environmental activities in district plans. The project has assisted communities surrounding the national park " to develop cultural tourism products and services (such as dance and drama shows and local cra7ts) and has provided fnancial and technical support to community-owned microenterprises. www.p 6b. 4 6g integRating PoPulation, HealtH, and enviRonment in Rwanda 8 Three health centers have been rehabilitated and adequately stocked " and sta77ed. These investments have increased access to health care 7or 15,000 people and helped to establish trust and goodwill among communities toward the project. The project has provided 7amily planning counseling and " communicated consistent reproductive health messages. As a result, contraceptive prevalence rates have increased in all three project sites 4ranging 7rom 14 percent in Kitabi to 38 percent in Rangiro 4 exceeding the 9 percent average at the three target health centers prior to project intervention. The Destination Nyungwe Project has identifed three main reasons 7or its early successes: Experienced implementing organizations and committed local " leadership. The project undoubtedly benefts 7rom the strong institutional capacity and experience o7 its 7our main implementing partners 4International Resources Group (IRG), Wildli7e Conservation Society (WCS), Family Health International (FHI), and the Cooperative League o7 the United States. Existence o7 appropriate political structures at the local level and local " leaders who are willing to help sensitize and mobilize communities to actively engage in project meetings and activities. Clear identifcation and engagement o7 key stakeholders and " target groups. MayanGe MillenniuM VillaGe PRojecT The Millennium Villages Project (MVP) is a United Nations initiative aimed at empowering and working with impoverished rural communities in 10 countries in A7rica to achieve the Millennium Development Goals within 10 years. The MVP aims to enable poor people to improve their quality o7 li7e by implementing comprehensive programs in agriculture, health, education, business development, in7rastructure, energy, and environment. To do this, the MVP brings together a range o7 experts, including scientists 7rom the Earth Institute at Columbia University and the World Agro7orestry Center (ICRAF), as well as local development pro7essionals and community-based organizations. Mayange Millennium Village is located in one o7 the driest and least populated areas (25,000 people) o7 Bugesera district in southeastern Rwanda. It was selected as a MVP site because o7 its high incidence o7 poverty, chronic 7ood insecurity, and high concentration o7 socially vulnerable groups, including orphans, 7emale-headed households, and newly resettled re7ugee returnees. A7ter an assessment o7 Mayange 9s most dire needs, three priority issues were identifed: agricultural productivity and 7ood security, health and sanitation, and environmental sustainability. Project activities began in 2006 and include integrated interventions such as: re7urbishment o7 existing health centers and establishment o7 new health posts in remote areas; distribution o7 treated mosquito nets; additional training 7or community health workers to provide home care services 7or HIV/AIDS patients, antenatal services 7or pregnant women, and increased access to 7amily planning; adoption o7 improved 7arming practices that conserve soil and increase water retention; and expansion o7 improved water coverage. The project has realized several notable achievements since its inception in 2006, including increased agricultural productivity, rehabilitation o7 health centers and improved health service delivery, provision o7 clean water, and increased primary and secondary school enrollments. Like the Destination Nyungwe Project, the Mayange MVP points to the importance o7 local leadership and community engagement to project success. The project has worked with community development committees (CDCs) and related local administration structures, created during Rwanda 9s decentralization process, to reach out to community members, recruit project advocates, and identi7y and support community leaders. Additionally, cross- sectoral collaboration and coordination has been strengthened by the 7ormation o7 a multisector institutional committee, involving members o7 key ministries and agencies, local government, donors, and civil society organizations. susTaininG PaRTneRshiPs To enhance RuRal enTeRPRise anD aGRiBusiness DeVeloPMenT PRojecT The Sustaining Partnerships to Enhance Rural Enterprise and Agribusiness Development (SPREAD) Project 7ocuses on improving rural livelihoods by supporting co77ee 7armers to grow, process, and market high-quality specialty co77ee. To do this, the project supports and strengthens co77ee cooperatives throughout Rwanda by linking them to the export market and improving their quality management. Additionally, the cooperatives have proved to be an e77ective mechanism to communicate conservation and health messages to mostly small, underserved 7arming communities. Early conservation and agribusiness results have been impressive. Farmers have invested in soil conservation measures and have A\xdter an assessment o\xd Mayange 9s most dire needs, three priority issues were identifed: agricultural productivity and \xdood security; health and sanitation; and environmental sustainability. 9 integRating PoPulation, HealtH, and enviRonment in Rwanda www.p 6b. 4 6g improved soil 7ertility by using organic manure instead o7 chemicals. With technical support 7rom the project, 7armers are able to address ine7fcient water use and pollution by installing water recycling and waste management systems. In addition, co77ee extension workers are now being trained to provide health care in7ormation during home visits and cooperative meetings. Due to poor transportation and communication networks in remote agricultural areas, this is the frst time that many 7armers have been able to access reliable in7ormation 4about 7amily planning, malaria control, immunization, sanitation and hygiene, HIV prevention, and nutrition. Perhaps most important, 7armers invested in health insurance 7or their 7amilies as a result o7 their increased incomes and possibly due to the increased health messages they received. In response to 7armers 9 requests, the project is partnering with local health organizations to implement additional health activities, such as providing 7amily planning and voluntary counseling and testing (VCT) 7or HIV services. RWanDese healTh enViRonMenT PRojecT iniTiaTiVe The Rwandese Health Environment Project Initiative (RHEPI) is a community-based initiative that aims to improve the health and well- being o7 the rural communities it serves by promoting sustainable agricultural practices and raising awareness about HIV/AIDS, nutrition, and water and sanitation issues. Operating in Rwanda 9s Eastern Province since 2006, RHEPI maintains two demonstration centers that showcase improved water and sanitation technologies (such as irrigation, water treatment/puri7ication, and water supply systems) and sustainable agricultural practices. In addition, the project trains 7armers to serve as resource persons in their own communities and works closely with churches to deliver integrated messages about water and sanitation, HIV/AIDS, environmental protection, and sustainable agriculture. RHEPI 9s low-budget, community-based approach has reached over 2,000 people living in the project 9s two targeted districts. Increasing Understanding of PHE Linkages The Rwanda PHE assessment identi7ied three communication channels that present opportunities 7or increased understanding o7 population-health-environment interactions at both policy and local levels: tr 7 a f( f$# 7! c$r)"s " . The post-genocide government was success7ul in implementing challenging programs like local justice, unity and reconciliation, and decentralization by deliberately invoking the cultures, traditions, and values respected and upheld by all Rwandans. Dialogues about program objectives, processes, and communities 9 needs and concerns took place within special community-level meetings, such as a monthly countrywide Primary school students learn about proper hygiene 7rom Destination Nyungwe Project (DNP) sta77 and teachers in Nyamasheke district in the Western Province o7 Rwanda. The DNP protects biodiversity by strengthening protected area management, mainstreaming environmental issues into district development plans, and promoting environmental awareness and stewardship in local communities. community-service obligation ( umuganda ), participatory planning meetings ( ubudehe ), and national dialogue sessions ( urugwiro ). With adequate planning and preparation, the PHE theme could be introduced and discussed at these important indigenous gatherings. m b a f 7 " . The media also provides opportunities 7or communicating PHE issues and integrated approaches. In Rwanda, state control over the media has loosened considerably since its divisive campaign during the genocide, and independent media is growing quickly. During the last three years, more than 10 additional private and community radio stations have sprung up in Kigali and around the country, several newspapers have begun publishing in di77erent languages, and Internet in7rastructure is expanding beyond the capital. These diverse media provide opportunities 7or PHE messages to reach local and national target groups. There are emerging best practices in health communication in Rwanda, such as Urunana by Health Unlimited and Family Health International, discussed 7urther below, 7rom which lessons could be applied to e77ectively communicate PHE messages through national and local media outlets. PHe n b(+$rk " . The newly established East A7rica PHE Network 4 launched in Addis Ababa in 2007 4will help improve communication about PHE issues among policymakers, researchers, and practitioners within Rwanda and throughout eastern A7rica. The PHE Network serves as a 7orum 7or in7ormation exchange about cross- cutting PHE issues, community networking, accessing resources, Pulcherie Mukangwije, Family Health International, 2008 www.p 6b. 4 6g integRating PoPulation, HealtH, and enviRonment in Rwanda 10 and advocacy 7or greater cross-sectoral collaboration across the East A7rica region. Country-specifc PHE working groups have been established in Ethiopia, Kenya, Rwanda, and Uganda. The Way Forward for PHE Planning and Integration In order to strengthen planning 7or cross-cutting PHE issues and promote cross-sectoral collaboration in Rwanda, the 7ollowing actions are suggested: c 7rry $)( 7# 7# 7!ys fs $ c f#s( f()( f$# 7! f#( br bs( f# 7# a 9 7p 7 9 f(y " c$r PHe f#( b dr 7( f$# . An in-depth stakeholder analysis would identi7y the institutions and organizations engaged in cross-cutting issues, how the issues or activities are interlinked, and the institution 9s or organization 9s capacity to e77ectively plan and implement cross-sector work. An in-depth analysis would also help identi7y specifc training needs, research and 7unding priorities, and potential partners and donors. d b* b!$p 7 cr 7" b+$rk c$r f#s( f()( f$# 7! 9$$r a f# 7( f$# 7# a " p$! f 9y a f 7!$ d) b . There is need 7or an interagency 7ramework that brings together di77erent pro7essionals, policymakers, and practitioners 7rom various disciplinary backgrounds and sectors related to PHE issues. Regular dialogues about approaches to integration and documenting and sharing practical case studies and best practices in East A7rica are needed. The establishment o7 the East A7rica Network and Rwanda PHE Working Group will help in this endeavor. Policy dialogue will require the design and implementation o7 an e77ective advocacy campaign to educate policymakers about PHE interactions and place PHE issues on the policy agenda. d b* b!$p 7 ")!( f" b a f 7 9$"")# f 9 7( f$# s(r 7( b dy " . Literacy rates are still low in Rwanda, with only 60 percent o7 women and 71 percent o7 men able to read and write; but most Rwandans listen to radio regularly. The Urunana Development Communication, a multimedia program implemented by Health Unlimited, has been success7ul in using radio and television to convey HIV/AIDS, reproductive health, malaria control, and other evidence-based health messages to the general public. This approach to health communication has been success7ul in other parts o7 the world as well, and has the potential to sensitize people to population-health-environment interactions and promote an integrated approach to development. exp!$r b (h b )rb 7# a f" b#s f$# $ c PHe f#( br 7 9( f$#s " . Increasing rural-urban migration is straining urban authorities 9 capacity to provide services. The congested, unplanned settlements are prone to health and environmental hazards such as poor sanitation and air quality and contaminated drinking water. The urban dimension o7 PHE interactions needs to be more 7ully explored to identi7y what and how policy responses can be designed to e77ectively address urban problems. This would also complement the government o7 Rwanda 9s strategy o7 encouraging sustainable urbanization as a way to promote rational land use. Raising awareness o7 the links between population, health, and environment among policymakers, development planners, and project implementers; strengthening institutional capacity 7or cross- sectoral collaboration; and ident7ying and supporting community leaders and advocates are essential 7or success7ul cross-sector integration in Rwanda. Progress in these areas will lay the 7oundation 7or more e77ective participatory development e77orts that increase human well-being and sustain healthy environments. 11 integRating PoPulation, HealtH, and enviRonment in Rwanda www.p 6b. 4 6g Acknowledgments Melissa Thaxton prepared this policy brie7. She is an independent consultant and 7ormer policy analyst at PRB. Special thanks go to Dr. Charles Twesigye-Bakwatsa o7 the Centre 7or Resource Analysis 7or serving as lead author o7 the Rwanda PHE Assessment 4on which this brie7 is based 4and to the members o7 the Rwanda PHE Assessment team: Timothy Karera, USAID; Eric Kagame, USAID; Alex Mulisa, Poverty-Environment Initiative and REMA; Pulcherie Mukangwije, Family Health International; Ian Munanura, World Conservation Society; James Rubakisibo, Rwandese Health Environment Project Initiative (RHEPI); and Dancilla Mukakamari, Association Rwandaise des Ecologistes (ARECO-RWANDA NZIZA). Thanks also to Roger-Mark De Souza, Sierra Club; Irene Kitzantides, USAID Global Health Fellow; John May, World Bank; and Jason Bremner, PRB, 7or reviewing various dra7ts o7 the brie7 and providing insight7ul comments and suggestions. References 1 The period between 1994, when the genocide ended, and 2003, when Rwanda 9s Constitution was adopted, is re7erred to as cthe transition. d 2 Charles Twesigye-Bakwatsa, Assessment o* Population, Health, and Environment Integration and Cross-Sectoral Collaboration in Rwanda (unpublished, 2008). For a copy o7 the report, contact popre7@prb.org. 3 John Pielemeier, Review o* Population-Health-Environment Programs Supported by the Packard Foundation and USAID (2005), accessed online at www.wilsoncenter. org, on Dec. 1, 2008; UNDP/UNEP Poverty-Environment Initiative, Pilot Integrated Ecosystem Assessment o* Bugesera (2007), accessed online at www.unpei.org, on Sept. 4, 2008; and Judy Oglethorpe, Cara Honzak, and Cheryl Margoluis, Healthy People, Healthy Ecosystems: A Manual *or Integrating Health and Family Planning Into Conservation Projects (Washington, DC: World Wildli7e Fund, 2008). 4 UNDP/UNEP Poverty-Environment Initiative, Pilot Integrated Ecosystem Assessment o* Bugesera . 5 Republic o7 Rwanda, Ministry o7 Finance and Economic Planning, Rwanda Vision 2020 (2000), accessed online at www.moh.go.rw, on Sept. 23, 2008. 6 The eight Millennium Development Goals are: 1) eradicate extreme poverty and hunger; 2) achieve universal primary education; 3) promote gender equality and empower women; 4) reduce child mortality; 5) improve maternal health; 6) combat HIV/AIDS, malaria, and other diseases; 7) ensure environmental sustainability; and 8) develop a global partnership 7or development. 7 Vision 2020 Umurenge 7osters 7urther decentralization in Rwanda by employing an integrated rural development model, which emphasizes local actions and interventions at the sector ( umurenge ) level. Rwanda is divided into province, district, sector, and cell administrative units. 8 Republic o7 Rwanda, Ministry o7 Finance and Economic Planning, 3 rd General Census o* Population and Housing o* Rwanda, 2002 (Kigali, Rwanda: National Census Service, 2003); and Carl Haub and Mary Mederios Kent, 2008 World Population Data Sheet (Washington, DC: Population Re7erence Bureau, 2008). 9 Final report pending: Institut National de la Statistique du Rwanda (INSR) and ORC Macro, Rwanda Interim Demographic and Health Survey 2007. 10 Institut National de la Statistique du Rwanda (INSR) and ORC Macro, Rwanda Demographic and Health Survey 2005 (Calverton, MD: INSR and ORC Macro, 2006). 11 INSR and ORC Macro, Rwanda Interim Demographic and Health Survey 2007 . 12 Twesigye-Bakwatsa, Assessment o* Population, Health, and Environment Integration and Cross-Sectoral Collaboration in Rwanda . 13 Julie Solo, Family Planning in Rwanda: How a Taboo Topic Became Priority Number One (2008), accessed online at www.intrahealth.org, on Sept. 5, 2008. 14 Twesigye-Bakwatsa, Assessment o* Population, Health, and Environment Integration and Cross-Sectoral Collaboration in Rwanda . 15 President 9s Malaria Initiative (PMI), Rwanda Country Profle, 2008, accessed online at www.fghtingmalaria.gov, on Nov. 12, 2008. 16 Twesigye-Bakwatsa, Assessment o* Population, Health, and Environment Integration and Cross-Sectoral Collaboration in Rwanda. 17 In coordination with the Ministry o7 Environment and various agencies, the Malaria Control Programme highlights an integrated strategy 7or prevention; vector control; access to treated mosquito nets and treatment; and improved water supply, sanitation, and hygiene. 18 UNAIDS/WHO, Epidemiological Fact Sheet on HIV and AIDS, 2008 Update: Rwanda (2008), accessed online at www.who.int, on Dec. 30, 2008. 19 United Nations General Assembly Special Session on HIV/AIDS, Country Progress Report Republic o* Rwanda, January 2008 , accessed online at www.unaids.org, on Nov. 23, 2008. 20 USAID, Rwanda Health Statistical Report, 2008 , accessed online at www.usaid.gov, on Nov. 10, 2008. 21 Lori Hunter, Wayne Twine, and Aaron Jacobs, Population Dynamics and the Environment: Examining the Natural Resources Context o* the HIV/AIDS Pandemic (Boulder, CO: Institute o7 Behavioral Science, University o7 Colorado at Boulder, 2005); Lori Hunter, Wayne Twine, and Laura Patterson, cLocusts Are Now Our Bee7: Adult Mortality and Household Use o7 Local Environmental Resources, d Scandinavian Journal o* Public Health 35, no. 69 (2007): 165-74; and Elin Torell et al., Guidelines *or Mitigating the Impacts o* HIV/AIDS on Coastal Biodiversity and Natural Resource Management (Washington, DC: Population Re7erence Bureau, 2007). 22 James Tobey et al., HIV/AIDS and Threats to Coastal Biodiversity in Tanzania: Cross-Sectoral Dimensions o* HIV/AIDS, Gender, and Population Dynamics in Critical Areas (Narragansett, RI: University o7 Rhode Island Coastal Resources Center, 2005). 23 Republic o7 Rwanda, Ministry o7 Finance and Economic Planning, Rwanda Vision 2020 . 24 National Institute o7 Statistics o7 Rwanda (NISR), Rwanda Development Indicators 2006 (Kigali, Rwanda: NISR, 2008). 25 Republic o7 Rwanda, Ministry o7 Finance and Economic Planning, Household Living Conditions Surveys 2000/01 and 2005/06, accessed online at www.devpartners.gov.rw, on Jan. 31, 2009. 26 Republic o7 Rwanda, Ministry o7 Health, Health Sector Policy , 2005, accessed online at www.devpartners.gov.rw, on Jan. 31, 2009. 27 Rwanda O7fce o7 Tourism and National Parks (ORTPN), Final Report o* the Community Consultations *or the Community Conservation Programme, 2004 (unpublished report). 28 Carl Haub, 2006 World Population Data Sheet (Washington, DC: Population Re7erence Bureau, 2006). 29 Pielemeier, Review o* Population-Health-Environment Programs Supported by the Packard Foundation and USAID . 30 To address the challenges o7 designing and monitoring complex integrated PHE projects, USAID 9s Population-Environment Program has provided fnancial and technical support 7or two recent publications. See Theresa Finn, A Guide *or Monitoring and Evaluating Population and Environment Programs (Washington, DC: USAID/Measure Evaluation, 2007); and Leona D 9Agnes and Cheryl Margoluis, Integrating Population, Health, and Environment Projects: A Programming Manual (Washington, DC: USAID, 2007). 31 The Destination Nyungwe Project is a fve-year, $5 million project 7unded by USAID. © 2009 Population Re7erence Bureau. All rights reserved. integRating PoPulation, HealtH, and enviRonment in Rwanda Policy BRiefs in PRB 9s cMaKinG The linK d seRies: Integrating Population, Health, and Environment in Rwanda (2009) Integrating Population, Health, and Environment in Ethiopia (2007) Integrating Population, Health, and Environment in Kenya (2007) Integrating Population, Health, and Environment in Tanzania (2007) Linking Population, Health, and Environment in Fianarantsoa Province, Madagascar (2006) Breaking New Ground in the Philippines: Opportunities to Improve Human and Environmental Well-Being (2004) Ripple E77ects: Population and Coastal Regions (2003) Women, Men, and Environmental Change: The Gender Dimensions o7 Environmental Policies and Programs (2002) Children 9s Environmental Health: Risks and Remedies (2002) Finding the Balance: Population and Water Scarcity in the Middle East and North A7rica (2002) 1875 Connecticut Ave., NW Suite 520 Washington, DC 20009 USA 202 483 1100 PHonE 202 328 3937 fax popre7@prb.org e-Mail PoPulaTion reference bureau www.prb.org PoPulaTion RefeRence BuReau The Population Re7erence Bureau infoRmS people around the world about population, health, and the environment, and emPoweRS them to use that in7ormation to advance the well-being o7 current and 7uture generations. PRB 9s Population, Health, and Environment Program works to improve people 9s lives around the world by helping decisionmakers understand and address the consequences o7 population and environment interactions 7or human and environmental well-being. For more in7ormation on the PHE program, please write to Jason Bremner at jbremner@prb.org. All publications are available on PRB 9s website: www.prb.org. M a k i n g t h e L i n k

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